What are the responsibilities and job description for the Director of Care Coordination position at Sullivan County Community Hospital?
QUALIFICATIONS
Education
Graduate from an approved school of nursing
Experience / Skills
Preferred experiences / skills include :
A minimum of 3-5 years experience in clinical or community health settings
Care Coordination, Case Management, or Home Health experience
Experience with health IT systems and data reports
Experience mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations
Ability to speak a relevant second language
Possesses required experience caring for chronic disease patients
Identifies and implements appropriate patient communication strategies and overcomes accessibility barriers, as required
Demonstrates essential leadership, communication, education, collaboration, and counseling skills
Shows proficiency in communication technologies (email, cell phone, etc.)
Possesses effective organizational skills
Demonstrates ability to maintain accurate notes and records
Required Licenses / Certifications
Registered Nurse licensed to practice in the State of Indiana
Health Coach Certification preferred but not required.
Working Conditions
Clean, well-lit, and well-ventilated environment
ROUTINE RESPONSIBILITIES
Behavioral Expectations
Consistently complies with established Behavioral Expectations
Management & Leadership Duties
Prepares monthly work schedule
Provides for adequate staffing within department
Participates in interviewing, hiring, evaluating performance, and counseling staff
Develops, reviews, and revises policies and procedures and enforces compliance
Acts as a role model and mentor to peers
Displays effective conflict resolution skills
Rotates work hours to provide for visibility and support to staff
Identifies opportunities for change / growth
Adapts and supports new initiatives
Exhibits knowledge of federal and state laws and regulatory agency standards
Attends and actively participates in appropriate committee meetings
Participates in department budgeting process
Facilitates monthly department staff meetings, maintains meeting minutes, and documents attendance
Coordinates classroom and clinical orientation of new staff and in-servicing for staff at unit level
Ensures staff competency relative to skills
Accepts other assigned duties and responsibilities as needed
Patient / Family Advocacy
Provides a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population
Coach patients / families toward successful self-management of their chronic disease
Uses tools and documents that support a guided care process and collaborates with patient / family toward an effective plan of care
Assess patient's and family's unmet health and social needs
Provides effective communications to improve health literacy
Develops a care plan based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan, as appropriate
Monitors patient adherence to plan of care and progress toward goals expeditiously, and facilitates changes as needed
Creates ongoing processes for patients / families to determine and request the level of care coordination support they desire over time
Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator)
Cultivates and supports primary care and sub-specialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
Documentation
Implements an effective internal tracking system for identified patients
Ensures effective tracking of test results, medication management, and adherence to follow-up appointments
Develops / supports systems to prevent errors (e.g., effective medication reconciliation and shared medical records)
Planning
Establishes new and revised departmental policies and procedures
Organizes and develops the annual departmental goals and provides leadership and interpretations to the staff
Projects changes in staffing based on new equipment, treatment trends, and average daily census
Projects new equipment and services requirements
Miscellaneous
Serves as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources
Facilitates and attends meetings between patient, families, care team, payers, and community resources, as needed
Attends and actively participates in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other NRACO Care Coordinators and Coaches)
Recognizes and responds to opportunities for improvement
Cultivates effective partnerships and effectively collaborates with all practice providers (physicians, nurse practitioners, and other licensed allied health team members)
Actively participates on all nursing or administrative committees, as assigned
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