Overview

 Coordinates care for clinic patients with medical providers, nurses and other staff to ensure continuity of care within established time frames and with efficient use of resources. Functions as a contact person for patient, family, community resources and health care team members internal to JHHS and referred care outside of JHHS for case management, discharge planning and continuity of care. Assists patients in obtaining health care, disability, insurance and welfare benefits. Manages staff and operations for personal care in the home.

Responsibilities

• Identifies, through Contract Health Services census review, referral and risk screening, appropriate patients requiring care coordination and case management. Assesses the patient/family needs in relation to the medical diagnosis, treatment and resources providing treatment options for continuity of care.
• Assesses patient level of function including developmental, physical, environmental, cognitive, behavioral, psychological, economic, social, cultural, and spiritual factors.
• Provides assistance to help patient recovery, understanding, discharge and/or management of an acute, chronic, or terminal condition; assistance may include education, referrals to JHHS clinic or community services, assistance with insurance coverage, acquisition of medical equipment, and information and referrals.
• Coordinates multidisciplinary care planning including patient care conferences to help resolve treatment decisions.
• Obtains necessary orders from medical providers to initiate home health referrals, personal care services, medical equipment, and continuity of care.
• Takes referrals for Personal Care Attendant (PCA) services and assigns the PCA worker with consideration of patient choice,
• Supervises PCA’s who do minor housework, laundry, food shopping, meal preparation, and assist with activities of daily living.
• Recommends selection of staff, trains staff and administers discipline as required.
• Establishes and maintains relationships with referral providers and hospitals.
• Identifies and qualifies patients for healthcare benefits and alternate resources.
• Serves as liaison between the community and Medicare, Medicaid, Veterans Administration, NM Health Insurance Exchange providers, medical services, private insurances, SSI, SSDI, state programs, and other applicable resources.
• Assists healthcare and other staff members to understand elements and requirements of Social Security Administration, Disability Determination Services and how to best help individuals with disabilities to obtain benefits.
• Collaborates with other departments such as Patient Registration, Medical Records, Billing, and Purchase/Referred Care, to update patient applications and information and to determine patient eligibility for care.
•  Maintains compliance with established Pueblo and department policies and procedures, quality assurance, safety, environmental, infection control and complies with requirements of accreditation and regulatory agencies.
• Establishes and maintains appropriate network of professional contacts.
• Enhances professional growth and development through participation in educational programs, workshops, and trainings.
• Contributes to the overall quality of the unit’s service provision by developing and coordinating work teams and by reviewing, recommending and implementing improved policies and procedures.
• Represents the Pueblo with dignity, integrity, and a spirit of cooperation in all relationships with staff and the public.

Qualifications

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Education and Experience:

Licensed Registered Nurse in State of New Mexico or Master’s degree in Social Work or a related field ; AND four (4) years of professional level discharge planning or casework experience in an ambulatory or acute care medical setting. 

REQUIRED CERTIFICATES, LICENSES, AND REGISTRATIONS:

• Valid New Mexico Driver’s License.
• Bachelor’s Degree of Science in Nursing or Master’s Degree in Social Work