Primary Purpose:

The person in this position is a member of the Patient Centered Health Care Home (PCHCH) team where each team member plays an integral role in providing patient-centered health care. The incumbent is responsible in the planning, implementation, and holistic care coordination of patients with complex and chronic illness in accordance to KPHC's Care Coordination Model and evidence based practice guidelines. S/he participates in healthcare innovation, leads projects, and activities that promotes quality patient care and improve health outcomes.

Essential Duties:

• Leads the PCHCH practice team in team-based communication, planning, developing, and implementing care coordination activities to improve patient outcomes.
• Assess the needs of patients and facilitates referrals and care coordination with internal and external stakeholders.
• Provides patient education, sets SMART goals, and establishes nursing care plan in accordance to the provider's treatment plan.
• Identifies gaps in the care of the patient and ensure that gaps are closed in alignment with NCQA-PCMH, HEDIS, and Health Plan requirements.
• Executes effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs.
• Provides staff training as it relates to care coordination and chronic diseases as appropriate.
• Organizes and coordinates chronic disease patient classes such as diabetes, asthma, CKD, memory clinic, etc.
• Works in concert with other teams to achieve the goals and objectives of the Patient Centered Health Care Home
• Implements policies, procedures, and processes developed by the PCHCH team.
• Ensures that KPHC's PCHCH team asserts changes based on the components of the chronic care model, KPHC guidelines & PCHCH model and plans for improvements are implemented.
• Provides oversight to support staff assigned to assist in care coordination activities.
• Prepares monthly report and updates to the senior management team and executive team as necessary
• Serves as a liaison for care coordination to insurance companies and other organizations
• Explores community resources and establishes partnerships to facilitate improvements.
• Supports other multi-cultural projects to enhance patient care.
• Performs direct nursing care such as triage, nurse advice and floor duties and/or covers other departments as necessary.

Administrative Responsibilities

• Supports and supervises support staff working with him or her.
• Maintain an awareness of services offered through the clinic and in the community to serve client needs.
• Maintain awareness of legal and legislative issues that may impact service availability.
• Participates in clinic quality improvements activities.
• Work in concert with the adult medicine care team to assess and modify quality improvement strategies.
• Maintains client confidentiality per clinic protocol.
• Develops and implements forms for data collection, tracking and documentation of activities and works with the adult medicine team to determine effective communication strategies.
• Work closely with other clinic staff engaged in activities or projects involving clients as it relates to chronic disease.

Regular and reliable on-site attendance is required.

Other Duties:

Perform other related duties as assigned

Observe safety and security procedures; determine appropriate actions beyond guidelines; report potentially unsafe conditions; use equipment and materials properly.

Minimum Qualification Requirements:

Skills/Knowledge:

Knowledge and skill in the delivery of community healthcare.

Knowledge of community resources, how to access such, and an awareness of government assistance programs.

Ability to assess and plan in a multi-cultural context.

Professionalism, sound clinical skills and emotional stability.

Ability to communicate comfortably with multi-ethnic populations.

Flexibility in program development and evolution.

Strong organizational skills.

Database creation and maintenance also desirable

Intermediate ability to use MS Windows including Word, Excel, PowerPoint and Access.

Demonstrates autonomy and self-direction in their work

Education:

Licensed LPN in the State of Hawaii required

Licensed RN in the State of Hawaii preferred

Bachelor of Science in Nursing preferred

Experience:

2 years general experience providing patient care in community or hospital setting.

1 year case management experience or experience providing health education and outreach activities

Kalihi-Palama Health Center is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.