Chronic Care Coordinator

Job title

Chronic Care Coordinator

Reports to

Rural Health Clinic Director

FLSA Status

Non-Exempt

Created/Revised

1/31/23; 1/24

Position Summary

The Chronic Care Coordinator is responsible for scheduling, organizing, and managing all aspects of a patient’s healthcare maintenance and treatment, including developing and implementing transition of care plans, ensuring the achievement of desirable patient outcomes, partnering with patients and families, linking with community resources, and conducting patient and family education. Implementation is accomplished through patient assessment, monitoring of the plan of care, reviewing activities, coordinating with the interdisciplinary team, communicating with providers, and by facilitating continuity of care across settings at Cherry County Hospital and Clinic.

Duties and Responsibilities

Responsibilities include but are not limited to the following:

• Coordinates and implements clinical care management/transition of care plan through partnership with the care team
• Assists with the identification and enrollment of high-risk patients (the chronically ill and those needing disease management)
• Assesses patient’s physical and mental wellness, needs, preferences, and abilities and uses them to develop tailored care plans in collaboration with provider and patient/family
• Monitors adherence to care plans, evaluates effectiveness, monitors patient progress, and facilitates changes if needed
• Interacts with providers to obtain orders, discuss treatment modalities or changes in the treatment, or any other aspect of care for positive patient outcomes
• Collects patient clinical findings and diagnostic reports for provider to review
• Communicates/implements findings and care recommendations to achieve targeted outcomes
• Participates in psychosocial management to include patient/family needs while facilitating referrals for evaluation; refers for mandated legal reporting (abuse and neglect)
• Educates patients about their condition, medication, and give them specific instructions
• Provide resources and options for managing patients’ health
• Listens to patient concerns and provides counseling or intervention as required
• Works with patient, family, and care team to develop goals and monitors progress
• Communicates with patients, family members, and the healthcare team about a patient’s treatment plan to achieve the best outcomes
• Complies with documentation requirements to include, but not limited to, care plan adherence, referrals, phone conversations, and home visits
• Assists patient and families in accessing community resources and scheduling appointments
• Participate in various incentive programs
• Assists patients with referrals to secure medical care as required
• Participates in continuing education programs on a yearly basis, and as needed
• Attends monthly staff meetings and shares knowledge of chronic care management as appropriate
• Ensures the confidentiality of patients’ medical, personal, and financial records is maintained
• Knowledgeable of and committed to practicing Corporate Compliance policies and procedures
• Complies with Cherry County Hospital personnel policies
• Performs other duties as assigned by supervisor

Skills and Abilities Required

• Excellent verbal and written communication skills
• Ability to provide service with compassion and empathy
• Requires a basic theoretical nursing knowledge with application of knowledge and skills
• Ability to make sound judgements and decisions concerning patient care
• Recognizes the proper channels of communication
• Knowledge of physical organization of the hospital, as well as the hospital policies and procedures
• Understands the legal aspect of nursing
• Ability to maintain complete confidentiality regarding patient care services
• Keeps abreast of new trends and developments in nursing.
• Interested in continuing professional growth.
• Has a preference for working with the public and other staff.
• Possesses personal qualities, which enable the nurse to maintain good interpersonal relationships and work well with people; examples of these are good judgement, understanding, loyalty, respect for the person as an individual, and empathy
• Must be knowledgeable of state and federal confidentiality laws, including but not limited to HIPAA, and be familiar with and follow all policies, procedures and instructions regarding the privacy and security of protected health information applicable to the position

Physical Demands and Working Conditions

• Work may be physically and emotionally demanding, involves lifting and positioning patients
• Environment requires working in close proximity with others in a clean, favorable area
• Physical demands require sitting for long periods of time, standing and bending as required
• Requires regular working hours with possibility of overtime
• Dexterity is needed to operate equipment, telephone, intercom system and other tasks as required to meet patient care needs
• Repetitive use of hands, arms, and eyes could cause strain
• Must be agile, able to move carefully around patients and equipment with ease
• Work involves the potential for exposure to hazardous material such as contaminated body fluids. Must possess the knowledge and insight to comply with universal precautions and hospital policies and procedures.

Direct reports

Clinic Manager

Minimum Job Requirements

• Graduate from an accredited school of nursing
• Possession of a license to practice as a Registered Nurse in the State of Nebraska
• Three (3) or more years of RN experience required