Reviewed January 2023

Job Title: Care Coordinator, RN

Department: Medical

Supervisor: Manager, Clinical Operations

Employment/FLSA Status: Full-time, Exempt

The Care Coordinator works closely with identified high-risk and complex patients including closing care gaps, and patients experiencing transitions in care. He/she provides guidance and advocacy to better promote the patient’s health. The Care Coordinator focuses on decreasing high ER utilization, hospital re- admission frequencies, and improving chronic illness conditions. He/she facilitates access to appropriate medical and specialty providers and coordinates timely communication between patient and primary care providers to improve health outcomes.

Areas of Responsibility

Patient Care and Education:

 Assesses the physical, functional, social, psycho-social, and environmental needs of patients.

 Provides education for patients and caregivers as needed, for understanding diagnoses, treatment options, illness progression, wellness and self-care measures.

 Increases continuity of care by managing relations with other care providers and

connection with community resources.

 Increases patient’s ability for self-management and shared decision-making.

 Provides medication reconciliation as requested by providers, in emergent or complex situations.

 Advocates for the patient and family, and protects patient’s autonomy, dignity, and

decision-making rights.

 Actively participates in team meetings, when appropriate, to support care management of the patient and in staff, supervisory, and clinical quality and risk management meetings.

 Responds to and facilitates referrals placed in EHR.

 Provides community visits, when appropriate, to gain a larger awareness of the patient’s healthcare barriers, and to offer suitable community resources as needed.

 Collaborates with other clinic disciplines to provide optimum patient care; provides telephonic triage of patients of high-risk and complex patients, if needed.

Reporting and Compliance:

 Provides clear, concise, and timely documentation, reflecting content and intent, for all patient interactions, recorded in EHR.

 Ensures that all Practice Policies are fully implemented; Ensures compliance with

professional standards & regulatory requirements.

 Develops, tracks, reports and retains care coordination program activities for internal and external reporting.

 Completes other duties as assigned by Manager, Clinical Operations.

Skills and Qualifications

Education and/or Experience:

 Associate of Nursing or License Practical Nurse and two years of clinic office nursing experience. Prefer Bachelor’s degree prepared Registered Nurse.

 Prior experience with chronic disease management of care and patient education

preferred.

 Experience with population health management concepts

 Unrestricted Georgia Registered Nurse license

Competencies:

 Attendance/Punctuality - Is consistently at work and on time, as established; ensures work responsibilities are covered when absent; arrives at meetings and appointments on time.

 Communications - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions; demonstrates group presentation skills; participates in meetings; writes clearly and informatively; edits work for spelling and grammar; keeps others adequately informed; selects and uses appropriate communication methods.

 Customer Service for Internal and External Customers/Patients - Manages difficult or emotional customer/patient situations; responds promptly to customer/patient needs; solicits customer/patient feedback to improve service; responds to requests for service and assistance; meets commitments.

 Job Knowledge - Competent in required job skills and knowledge; exhibits ability to learn and apply new skills; keeps abreast of current developments; requires minimal supervision; displays understanding of how job relates to others; maintains confidentiality per policy and regulations; fluent in Microsoft Office programs, including Word, Excel, PowerPoint and Outlook and job related software and computers; uses resources effectively; pursues training and development opportunities; adapts to new technologies; keeps technical skills up to date.

 Problem Solving - Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics; adapts to changes in the work environment; changes approach or method to best fit the situation.

 Planning/Organizing - Prioritizes and plans work activities; uses time efficiently; plans for additional resources; sets goals and objectives; organizes or schedules other people and their tasks; develops realistic action plans.

 Quality Management - Looks for ways to improve and promote quality; demonstrates accuracy and thoroughness; applies feedback to improve performance; monitors own work to ensure quality.

 Safety and Security - Observes safety and security procedures; determines appropriate action beyond guidelines; reports potentially unsafe conditions; uses equipment and materials properly.

 Teamwork - Exhibits objectivity and openness to others' views; gives and welcomes feedback; establishes and maintains effective relations; exhibits tact and consideration; offers assistance and support to co-workers; works cooperatively in group situations; works actively to resolve conflicts.

Physical Demands:

 The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 While performing the duties of this job, the employee is regularly required to use hands. The employee is occasionally required to stand; walk; sit; reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds.

Organization Description

In 1995, Dr. George W. Brumley, former Chair of Pediatrics at Emory University School of Medicine, and his former student, Dr. Veda Johnson, established Whitefoord, Inc. to address the health and educational needs of children and families of the Whitefoord Elementary School District in southeast Atlanta. Through an in-school health center and a child development program, Dr. Brumley and Dr. Johnson made a crucial connection between health and academic success: healthy children stayed in school and achieved more.

From its roots in health and education, Whitefoord soon grew beyond the in-school health center at Whitefoord Elementary School to meet even more clinical needs of children and families. In 2003, Whitefoord established as a Federally Qualified Health Center (FQHC) and after 17 years of operating health centers only in schools, opened its first-ever community-based Family Medical Center in the Kirkwood neighborhood in the fall of 2012 to treat children and adults.

Whitefoord operations currently consists of:

 Whitefoord Health Center

o a 5,500 square foot, purpose designed and built ambulatory medical center opened in September 2020 providing the following clinical services

 Medical

 Dental

 Behavioral Health

 Whitefoord Elementary School Health Center

o This is the original Whitefoord school based health center location that previously served the students of Whitefoord Elementary School until the school closure in 2017

o Currently operates as a Whitefoord dental care location

 School-Based Health Centers

o Toomer Elementary School

o King Middle School

o KIPP Woodson Park Academy

 YMCA Early Learning Center

o Whitefoord has partnered with the YMCA Early Education program to provide well child screenings at several YMCA Early Education locations

 Whitefoord Early Learning Academy (WELA)

o Early education program for students from six weeks to Pre-K

o Located in the former Whitefoord Elementary School building

We are extremely proud of our 2 decade history of achievement and positive impact on the Edgewood and East Atlanta communities and are equally excited about our growth opportunities going forward. In order to add to our team and accomplish our intended goals, we seek to attract candidates who are laser focused and committed to improving the lives of our patients, students and families.