The Coordinator will serve as a liaison between the patient and family, primary care physician, internal and external care providers, specialists, support network members e.g. social workers, and the wider healthcare community. Facilitate NICU discharge process by arranging follow up appointments, making follow up phone calls and providing educational support, minimizing stress as families adjust to life at home. Collaborate with our staff at the Next Step Developmental Clinic.
Duties include but are not limited to:
· Work collaboratively as a team of coordinators, prioritizing and delegating projects as the Center grows.
· Serve as patient advocate from enrollment in the “ Program”
o Initiate contact with patient and introduce navigation program and role at time of diagnosis (or at entry into the HCA care system, if later).
o Be available to patients and families throughout their care as an open, knowledgeable and empathetic contact for all care needs.
o Respond to patient challenges until resolution is achieved.
· Assess the medical, social, and psychosocial and other care needs of the patient and family
o Identify health disparities and remove barriers to care e.g. referral pathway barriers
· Provide appropriate teaching, outreach, and education to patients and families. The aim of this work being to ensure the patient is empowered to manage his or her own health.
o Support providers to assist patients in understanding their diagnosis, treatment options, and the resources available, including educating eligible patients about appropriate clinical research studies and technologies.
o Provide education on subjects that fall beyond the scope of individual modalities e.g. access to supportive care, financial support, return to work.
o Provide education through formalized routine groups or classes to meet identified unmet needs in the community
· Streamline appointments and paperwork by helping patients with scheduling appointments and preparation.
o Ensure the organization of appointments, and explain the sequence of treatment to assure the treatment plans are being met.
o Ensure smooth transitions between care modalities, facilities and providers including introduction of patients to appropriate care givers.
· Establish algorithms, documents, and formalized processes for transition in commonly followed care pathways.
· Coach and help patients to remove barriers with issues of insurance, transportation, child care, financial resources, language so they may focus on getting the care they need.
· Initiate referrals to hospital and community resources to connect patients with resources and support systems.
· Conduct follow-up conversations as needed with all patients and communicate concerns, changes, or social needs in patient health to appropriate MD or other appropriate care providers.
· Organize and attend patient care planning conference and other meetings as necessary.
o Ensure that appropriate patient data is available and patients are appropriately assessed and documented at patient care planning conferences including identification of appropriate clinical research study options.
o Contribute as appropriate to patient care planning conference based on assessed patient need.
· Track and document interventions and outcomes.
o If appropriate, support definition of datasets and ensure appropriate data are collected to track system interventions and outcomes.
o Ensure appropriate communication of patient progress to referring physicians and other care providers.
o Work with data experts to support collection of data for e.g. national quality measures.
· Drive process improvement.
o Ensure reporting is in place to demonstrate program outcomes and support performance improvement activities.
o Make appropriate recommendations for changes to the current program both locally and at a corporate level, and assist in delivering program improvement.
· Conduct outreach to referrers, providers and other medical professionals as well as to the community
o Establish and maintain positive working relationships with key internal and external customers (including e.g. physicians, nurses, radiology staff, social services staff, radiation, business office staff, etc.).
o Educate each constituent on the role and benefits of a navigation program and high quality care.
o Recognize scope and limitations of role and regularly access supervision as a support to the role.
o Provide referring providers with timely data on patient progress.
· Stay current on the latest nursing developments and participate in conferences.
· Ability to articulate the benefits of Minimally Invasive Surgery (MIS) in our tiniest patients, to emphasize this strength of our program’s medical team.
· Ensure service continuity.
o Establish appropriate mechanisms to ensure service continuity during both planned and unplanned absence and undertake succession planning.
· Undertake other duties as assigned.
Current licensure as a registered nurse in CO, certification in Basic Cardiac Life Support (BCLS), Specialty Certification achieved or in progress
Bachelors of Science in Nursing (BSN) from an accredited school of nursing.
Advanced Practice Registered Nurse or MSN, MHA, Participation in professional organizations
Minimum five years Labor and Delivery, NICU or Pediatric nursing experience
Experience in program development, experience as a nurse navigator and / or patient educator , experience in leadership, experience in customer service
D. Special Qualifications:
Bilingual skills strongly preferred, Skilled in use of Microsoft office software. Comfort with website management and marketing initiatives.