The incumbent in this position acts as an advocate for patients serving as the primary point of contact and is responsible for coordinating the care and services of the identified patient populations for an extended period of time across the continuum of care for both inpatient and outpatient services; promoting effective resource utilization; assuming a leadership role with the multidisciplinary team to achieve an optimal clinical outcome.

Essential Job Functions

•Supports and models behaviors consistent with the mission and philosophy of Billings Clinic and department/service.

•Facilitates the coordination of patient care services to assure excellence in patient care and patient flow; includes coordinating care, treatment and communication among the medical team

•Follows patient through the care continuum/experience, eliminating operational (such as scheduling, test results, etc.) barriers to services.

•Works closely with other healthcare disciplines to ensure timely appointments, results reporting, financial need referrals, communication, patient care and follow-up

•Facilitates the development, implementation and adherence to clinical and evidenced based guidelines, as appropriate, to ensure optimal clinical outcomes

•Ensures follow-up on identified patient clinical and non-clinical care, facilitating communication and compliance to care plans (i.e., medication reconciliation, follow-up on care concerns/critical values/core measures, patient care conferences, etc.) Ensures follow up has occurred regarding patient clinical and non clinical care to include adherence to plans of care, resource utilization, and general progress utilizing care conferences as necessary.

•Works in collaboration with the medical team to develop and implement clinical guidelines. Facilitates the adherence of the guidelines through regular evaluation and auditing of clinical practice.

•Works with care team to assure direct care needs are met, assisting as needed or assigned

•Ensures follow-up in the inpatient and/or outpatient setting on identified patient clinical and non-clinical care, facilitating communication and compliance to care plans (i.e., medication reconciliation, follow-up on care concerns/critical values/core measures, patient care conferences, etc.)

•Demonstrates expertise in educational and resourcing services

•Participates in educational activities related to patient/community, clinical operation and process issues on an ongoing basis

•Collaborates with other health care providers in developing, implementing and evaluating educational materials for patients and their families

•Facilitates intra-departmental relationships in an effort to provide necessary resources to and for the patient.

•Interfaces with other members/disciplines within the healthcare teams for appropriate referrals/services

•Aware of and assists with financial needs of the patients.

•Identify and access appropriate social services, including resources to assist caregivers to support treatment

•Develop options for complementary and integrative care – IM would not necessarily support this.

•Contributes to an environment of quality and process improvement

•Ensures accurate and timely data collection and entry into patient database as indicated by department guidelines

•Directs and coordinates identified quality assessment and improvement activities to assure quality patient services are monthly provided through audits and reviews other identified evaluation tools

•Ensures patient care activities for the department services are monitored monthly through audits and reviews

•Ensures and enhances facility, safety, and regulatory outcomes

•Complies with all applicable laws, regulations and accrediting agencies

•Complies with all Billings Clinic policies

•Works in collaboration with Leadership team to ensure hospital and clinic departmental goals and objectives are met.

•Supports the hospital and clinic departmental goals

•Contributes to community activities sponsored by the department

•Develops patient referral services by relationship-building strategies with physicians not related to the department.

•Performs other duties as assigned or needed to meet the needs of the department/organization.

•Works as an active team member and effective communicator

•Demonstrates effective internal and external communication strategies, written and verbal, to assure a collaborative environment

•Ensures appropriate and timely documentation

•Demonstrates a productive work ethic while on duty

•Works consistently as an active team player, inter-and intra-departmentally

•Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.

•Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.

•Assists Mammography provider throughout imaging guidance breast biopsy procedures.

•Identification and assistance for patients in potential benefit for genetic testing evaluation.

•Organization and record maintenance of appropriate record needs required for accreditation purposes.

•Performs other duties as assigned or needed to meet the needs of the department/organization.

• Additional Duties for Breast Diagnostics

•Facilitates the coordination of patient care services to assure excellence in patient care and patient flow.

•Follows patient from abnormal mammogram through diagnosis.

•Provides seamless patient flow from abnormal mammogram to diagnosis and referral to breast Patient Care Navigator

•Facilitates breast biopsy scheduling

•Facilitates breast biopsy education

•Facilitates the development, implementation and adherence to clinical and research guidelines, as appropriate, to ensure optimal clinical outcomes

•Ensures that each patient scheduled for a screening mammogram has had a clinical breast exam within acceptable time frame.

•Demonstrates expertise in educational and resourcing services

•Facilitates relationship between physicians, vendors, departments and the breast multidisciplinary program

•Interfaces with finance and breast imaging services to meet the financial needs of the patients

• Additional Duties for Regional Navigator

•Collaborate with local individuals, agencies and organizations to facilitate the increased availability of community-based care services.

•Facilitates research participation opportunities through outreach clinics.

•Facilitates increased utilization of telemedicine in connecting rural patients and providers to Billings Clinic resources.

•Coordinate opportunities to increase prevention awareness and offer early-detection screening programs in outreach areas.

•Develop and implement regional care protocols, resulting in reduced time to problem resolution and improved quality of care.

•Interfaces with local and outreach providers in addressing care navigation concerns.

•Identifies community support services in underserved and frontier areas and facilitates utilization of these services.

•Advocates for the individual and collective needs of patients in rural and frontier areas.

•Facilitates relationship-building between physicians, agencies, and organizations.

•Interfaces with physicians, agencies, and organizations to meet the medical, social, and financial needs of patients.

• Additional Duties for Heart Failure

•Monitors heart failure program participants using nursing assessment skills through phone conversations, in clinic nursing assessments and follows protocols in problem solving/treatment. Reports inappropriate responses or concerns to appropriate provider (cardiologist, cardiology mid-level, primary care provider, social worker, etc.).

•Maintains appropriate theoretical and clinical skills with application and patient relevance of commonly utilized equipment specific to the Cardiac Services Department and Heart Failure Program; pharmacological application; application of laboratory values and radiologic findings with disease process or physiological status.

•Triage of incoming patient acute need phone calls of the day for either symptom management or nurse visits

•Follow up education and compliance assessment on all hospital and ED discharges for established primary care patients

•Complex Chronically Ill and Health Maintenance registry population management.

•Collaboration with other departmental Patient Care Navigators and Care Managers.