77040-9, Clinical Care Coordinator (RN)

Essential Functions:

• Attention to Detail
• • Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.
  • Implement an effective internal tracking system for identified patients.
  • Coach patients/families toward successful self-management of their chronic disease.
  • Assess patient and family’s unmet health and social needs.
  • Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
  • Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
• Integrity
• • Core values consistent with a patient/family-centered approach to care.
  • Demonstrates a positive, respectful attitude and professional customer service. Acknowledges patients’ rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
  • Demonstrates professional practice behavior.
• Cooperation
• • Provide effective communications to improve health literacy.
  • Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator, Dietician).

• • Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
  • Demonstrates professional and effective written and verbal communication skills.

• Dependability
• • Attend and actively participate in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other Care Coordinators and Coach).
  • Demonstrates understanding in use of IT resources and patient databases.

• Compliance
  • Promotes and adheres to the provisions of the compliance program.
  • Communicates the mission, ethics and goals of the facility.
  • Complies with all organizational policies regarding ethical business practices.
  • Promotes and adheres to the TVHS core values and Standards of Behavior.