Reports to the Manager, Director or Executive Director of Beacon Care Coordination, Population Health Department. Coordinates and manages outcomes of a specific patient population to facilitate achievement of quality, service, and cost. Ensures smooth transitioning of care from inpatient setting to post-acute care settings, community services, or physician offices. Works collaboratively with other Care Coordinators and interdisciplinary staff, internal and external to the organization. Prepares summaries, reports, and profiles pertaining to patient cases, quality metrics and organization goals. Assists in facilitating case reviews and other interdisciplinary meetings. Identifies and evaluates patient and family needs for education, socio-economic support, navigation. Provides in-person or virtual teaching, transmits care goals to appropriate care providers, connects patients and families with appropriate resources. Establishes and facilitates effective relationships with physicians, staff, patients, and families.
MISSION, VALUES and SERVICE GOALS
MISSION: We deliver outstanding care, inspire health, and connect with heart. VALUES: Trust. Respect. Integrity. Compassion. SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Coordinates patient care within established caseloads throughout the entire continuum of care, spanning each area in which care is provided by:
Assuring patient has smooth transition from hospital to post-acute care settings.
Networking with physicians and other health care providers to assure effective implementation of patients' plans of care and establishment of desired patient outcomes.
Screening patients for clinical needs, condition stage, understanding level, socio-economic needs and other variables.
Educating patients in condition management and referring patients with chronic illness to appropriate services.
Assisting as liaison between family, inpatient care providers, outpatient providers, case management and other inter-disciplinary team members by interpreting the plan of care to patients, families, and others.
Monitoring patient care and concurrently tracking variances.
Referring variance trends to Manager/Director/Executive Director or appropriate physician reviewer for review and action.
Assisting with discharge by assuring coordination of community services, follow-up care, and education.
Reviewing patient medical records to monitor completeness and accuracy, including medical issues not addressed prior to discharge.
Coordinating the gathering and reporting of patient outcome information post discharge.
Participates in continuous quality improvement by:
Compiling and analyzing data to generate reports which accurately represent utilization trends and patterns.
Making recommendations to appropriate committees to improve overall quality of patient care.
Preparing summaries and reports for review by the Manager/Director or Executive Director.
Contributes to closing gaps in care.
Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:
Completing other job-related assignments and projects as directed.
Education and Experience
The level of knowledge, skills and abilities indicated below are normally acquired through the successful completion of a Practical Nursing Program (current LPN license in State of IN) or Masters in Social Work (MSW).
Minimum of three years related clinical experience and experience in educating and managing various chronic illnesses.
Knowledge & Skills
Requires thorough knowledge of clinical care practices, procedures and techniques required to meet targeted patient population.
Requires comprehensive knowledge of chronic disease states and managing illness.
Requires working knowledge of research methodology.
Demonstrates effective analytical and problem-solving skills.
Demonstrates proficiency in nursing assessment skills.
Demonstrates clear, effective communication skills, including verbal, written, and listening skills.
Demonstrates well developed interpersonal skills necessary to promote and maintain cooperative, courteous, and sincere relationships with patients, family members, physicians, staff, and the public.
Requires ability to independently prioritize and organize work activities and work effectively under pressure.
Requires ability to identify and utilize appropriate resources. Demonstrates computer literacy and the ability to effectively use word processing, spreadsheet, and electronic health record and presentation software.
Works in various environments including patient care areas with frequent changes in job demands.
Requires the physical ability and stamina to perform the essential functions of the position.
Clear communication and speaking voice for telephone speaking required.