Facility: Avalon Health Park

Job Summary: The Care Coordinator serves as a liaison and coordinator of services for a specific population of patients. The Care Coordinator engages patients in clinic services and guides and assists with the coordination of care between clinic and external services, and across the continuum of care. The Care Coordinator works collaboratively with physicians and multidisciplinary teams to ensure timely and effective access to care. Core Responsibilities and Essential Functions: Coordination of Services Receive incoming referrals and schedule patient with appropriate specialist Coordinate patient flow through clinic to efficiently utilize time, space, and professional resources. Work with referring physician office staff to ensure patients have competed all diagnostic tests and results are available before clinic appointment. Contact patients for missed appointments. Explain purpose and process of the program to patients during initial contact. Serve as liaison between patient and physicians for information and schedules. Participate in community outreach related to program and services. Identify patients who will benefit from the program and help with barriers including but not limited to insurance, financial issues, need for personal support, mobility or sensory deficits, transportation, and language. Collaborate with all stakeholders of the program to provide quality comprehensive care to patients. Maintain and disseminate current information about medical and community resources. Make appropriate referrals to agencies and services for optimal resource utilization and patient satisfaction. Evaluate outcomes of interventions and services and revise strategies as needed Be available to patients and staff as resource for information, schedules, questions, and concerns. Coordinate care across the continuum to ensure successful care transitions. Serves as a resource to the clinical team by providing education about the program. Information Management Establish and maintain medical record for each patient. Gather and disseminate patient information to clinical staff in timely manner. Facilitate Performance Improvement activities with primary focus on patient outcomes and clinic efficiency. Work with other team members as necessary for billing, records, schedules, compliance, clinic statistics etc. Coordinate and/or participate in meetings, committees, related public or marketing events for the program, as needed. Professional Practice and Responsibility Exemplary Practice and Outcomes A. Practices within the scope and in accordance with Nursing Practice Standards and Code for the Licensed Practical/Vocational Nurses put forth by the National Federation of Licensed Practical Nurses, Inc. (NFLPN). B. Promotes health promotion in the performance of clinical care using evidence based practice, uses analytical/critical thinking and ensuring that care is individualized; coordinating care through effective partnerships recognizing that caring is central to achieve optimal patient care outcomes C. Practices using current clinical practice standards. Teamwork and Collaboration A. Coordinates the delivery and documentation of safe quality patient care that promotes the professional care delivery model. This includes, but is not limited to diverse and inclusive interdisciplinary communication methods (interdisciplinary rounds, case review, etc.); completion of timely documentation and promotion of a respectful, inclusive clinical environment. B. Demonstrates teamwork and collaboration by practicing in a manner that is fiscally responsible. Professional Development and Initiative A. Completes all initial and ongoing professional competency assessments, required mandatory education, and licensure requirements. B. May delegate tasks to unlicensed staff, as appropriate and within their scope of practice. Evidence Based Practice and Research A. Promotes Evidence based practice, nursing research and performance improvement in nursing. Participates in shared decision-making groups and committees as able. B. Upholds all health care system/organizational policies and procedures and clinical competencies put forth by this job description and professional association including legal, regulatory and accreditation requirements and standards ensuring by way of example, such goals as TJC Patient Safety Goals and WellStar Health Systems safety absolutes. Required Minimum Education: Diploma from an accredited nursing program Graduate from a practical or vocational nursing program Required Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated.

• Basic Life Support or BLS - Instructor
• Lic Practical Nurse

Additional License(s) and Certification(s): Required Minimum Experience: Minimum 2 years 2 or more years of adult acute or ambulatory clinical experience. Experience in area of specialty supported may be required. Required Required Minimum Skills: Self-directed and able to organize and complete several tasks simultaneously. High Ability to communicate clearly and effectively verbally and in writing with physicians, staff, patients, public and other members of the healthcare team. High Excellent attention to detail. High Proficient in review, analysis and maintenance of medical records and other patient care information. High