To promote patient, family, staff and physician satisfaction through coordination and continuity of care. To provide a systematic approach to the evaluation of patient care. To coordinate patient care through the continuum thereby facilitating the achievement of optimal quality outcomes in relation to clinical care and cost effectiveness.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Under the supervision of Director of Case Management and population health along with the general direction of Primary Care Providers, care coordinators perform the following functions:

1. Reviews and coordinates all aspects of care for patients in the practice who are identified as high risk or in need of care coordination to promote efficient coordination of care through the health care system.

2. Develops and implements a comprehensive and collaborative care plan based on the treatment needs of the patient, using evidenced based chronic care guidelines.

• Care plans are an individualized approach to a patients care to help all involved better manage the overall patient care needs. Care plans consist of , but are not limited to:

o Goals for a patient's health status

o Resources necessary to benefit the patients care

o Timelines and re-evaluation schedules

o Collaborative approaches to improved health

3. Provides nursing care via face to face nurse visits, electronically and telephonically to best meet the needs of the patient and family.

4. Assists in the development of short and long term goals.

5. Facilitates communication between patient, family, providers, team members within and external to the practice, specialists, other providers, social workers, therapists and community resources.

6. Ensures completeness of and access to patient's health information and care plan by appropriate disciplines.

7. Identifies patients needs in regards to transitions of care from site to site and provider to provider.

8. Works with the medical team to identify needs of the patient and family and refer to appropriate community resources. Assures safe home environment, conducts safety evaluations.

9. Monitors patient's health status and ability to manage health/chronic illness.

10. Provide individual patient/family education and self management support based on language, cognitive ability, literacy, learning style, cultural norms, patient preference, readiness for change and resources available.

11. Follows up with patients post provider visits to assess understanding of and ensures productive, effective patient provider interactions.

12. Coordinate and conducts patient education sessions (one on one and group formats). Assists in coordination of medical appointments/group visits.

13. Tracks referrals and test results, shares information and educates the patient about the results. Assures the patients receive appropriate follow-up based upon test results.

14. Coordinates the patients care amongst specialists and other disciplines, arranges for special accommodations, and works with the patient to decrease barriers to accessing care.

15. Works with patient to provide an understanding of treatment recommendations.

16. Maintains environment characterized by trust, acceptance, recognition and respect.

17. Complies with safety and emergency procedures consistent with policies and procedures.

18. Reports possible problematic situations to the practice manager. Reports problems of a clinical nature to the physician(s).

19. Assists with monitoring, assessing and implementing quality assurance measures.

20. Participates in quality assurance activities and all training seminars, OSHA and others.

21. Demonstrates courtesy, respect and caring to patients, families, physicians and staff, and maintains professional rapport with all external parties and organizations.

Qualifications

Education:

• Graduate from an approved school of nursing.
• BSN preferred.

Experience:

• A minimum of two or more years of professional nursing experience
• Medical office experience preferred.
• Case management experience preferred.

Licensure / Certification:

• Current registration in the State of NH as a Registered Nurse.

• Basic Life Support (BLS) certification required.