Description
Description
HOW WE CARE FOR YOU
At St. Lawrence Health, we are dedicated to getting health care right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for your career while caring for the community.
SUMMARY
The Care Coordinator works in collaboration and continuous partnership with chronically ill or "high-risk" patients and their family/caregiver(s),clinic/hospital/specialty providers and staff, and community resources in a team approach. Facilitates "shared goal model" within and across settings to achieve coordinated high-quality care that is patient and family centered that address. Acts as a liaison between patients and the healthcare system. Ensures that patients receive the care they need and that they understand their medical condition, medications, and other instructions. Coordination of patient-care services to help reduce costs by reducing duplication of services.
STATUS: Temporary
LOCATION: Massena Hospital
DEPARTMENT: Behavioral Health
SCHEDULE: M-F, 8am-4pm
ATTRIBUTES
- 3-5 years' experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.
- Experience with Patient-Centered-Medical Home desirable.
- Completion of an accredited Registered Nurse training program. BSN preferred.
- Certification through the American Academy of Ambulatory Care Nursing in Care Coordination and Care Transitions required within 18 months of employment required.
- Chronic Disease Self-Management Certification required within 12 months of employment.
- Willingness to obtain ongoing and up to date population specific education
- Care Coordination: Systematically identifies individual patients and plans, manages and coordinates their care, based on condition, needs and on evidence-based guidelines based on quality goals of organizations and population needs.
- Provides assessment, care planning and coordination, and advocacy to patients and their families.
- After assessing the health status of patients, develops, formulates, implements, and revises self-management care plans with a shared-goal model, incorporating patient specific education as appropriate for high risk patients and others, as defined by the practice.
- Evaluation of patient responses to interventions, identifying and developing strategies to barriers in achieving positive clinical outcomes.
- Coordinates care with community and regional ancillary health services for extended needs of patients and ensures that patient specific care plans are developed and documented by the practice clinical team.
- Educates patient/family regarding relevant wellness issues, disease process, and treatment plan, if not bringing to the attention of the physician.
- Educates patients with appropriate method suitable for individual learning abilities regarding diet, medication, or test needs, if not bringing to the attention of the physician.
- Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
- Promote timely access to appropriate care.
- Increase utilization of preventative care.
- Reduce emergency room utilization and hospital readmissions.
- Increase comprehension through culturally and linguistically appropriate education.
- Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).
- Increase continuity of care by managing relationships with tertiary care providers,
Compensation Information:
$0.0 / - $0.0 /
Starting At: 0.0
Up To: 0.0
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