RN Care Coordinator - Pcmh

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Trumbull, CT
Apr 3, 2019


Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.


Care Coordinator, Patient Centered Medical Home: Reports to the Director of Ambulatory Care Coordination and works in collaboration with physicians, staff and other healthcare professionals. The care coordinator works within the context of a primary care medical home, from a team approach, and in continuous partnership with families and physicians to promote: timely access to needed care, comprehension and continuity of care, and the enhancement of patient and family well being. Coordinates appropriate resources to facilitate and ensure the patient's progress through the continuum of care. Actively participates in the quality review process and assures continual improvement of patient safety, clinical practice and quality patient care. Is an integral member of the health care team who works to ensure safety, best practice and high quality standards of care are maintained across the continuum of care. Responsible for coordinating a wide range of self -management support and disease registry activities. Success will be measured by the results of the process and outcome performance measures of the population of patients in the clinic. Works closely with the patient care team and key collaboratives across YNHHS, NEMG staff, PM staff, hospital based Care Coordinators and Community based resources. The patient care team may include home health and other hospitals /facilities outside the Yale New Haven Health System.

  • 1. Demonstrate and apply knowledge of the philosophy/ principles of comprehensive, community based, family-centered, developmentally appropriate, culturally sensitive care coordination services
  • 2. Facilitate patient and, as appropriate, family access to medical home providers, staff and resources
  • 3. Assist with or promote the identification of patients in the practice with special health care needs or patients at high risk; add to registry and use to plan and monitor care
  • 4. Assess patient and family needs and unmet needs, strengths and assets
  • 5. Initiate patient and family contacts; create ongoing processes for patients and families to determine and request the level of care coordination support they desire at any given point in time
  • 6. Build care relationships among patient, family and team; support the primary care-giving role of the family when appropriate
  • 7. Develop care plan with patient, family, and team (emergency plan, medical summary and action plan as appropriate)
  • 8. Carry out care plans, evaluate effectiveness, monitor in a timely way and effect changes as needed; use age appropriate transition timetables for interventions within care plans
  • 9. Serve as the contact point, advocate and informational resource for patient, family and community partners / payers
  • 10. Research, find, and link resources, services and supports with/for the patient and family
  • 11. Educate, counsel, and support; provide developmentally appropriate anticipatory guidance; in a crisis, intervene or facilitate referrals appropriately
  • 12. Cultivate and support primary care & subspecialty co-management with timely communication, inquiry, follow up and integration of information into the care plan
  • 13. Coordinate inter-organizationally among patient, family, medical home, and involved agencies; facilitate ?wrap around? meetings or team conferences and attend community/school meetings with family as needed and prudent; offer outreach to the community
  • 14. Serve as a medical home quality improvement team member; help to measure quality and to identify, test, refine and implement practice improvements
  • 15. Coordinate efforts to gain patient and family feedback regarding their experiences of health care (focus groups, surveys, other means); participate in interventions which address articulated needs
  • 16. General RN Duties.
  • 16.1. Types correspondence (memos and letters), statistical forms and procedures and is able to maintain complete patient records while keeping complete patient confidentiality.
  • 16.2. Maintains confidentiality of patient, personnel, and institutional information.
  • 16.3. Demonstrates effective organizational skills.
  • 16.4. Demonstrates current level of knowledge of various payor regulations
  • 16.5. Demonstrates clinical leadership as evidenced by previous work related activities and performances.
  • 16.6. Demonstrates expert practice skills that include flexibility, priority setting, problems-solving, conflict resolution, negotiating and networking skills, decision-making, work delegation and organization, and verbal/written communication skills.
  • 16.7. Accurately and legibly documents all patient interactions in the patient record.
  • 16.8. Demonstrates self-directed learning needs and seeks ways to meet own professional development.
  • 16.9. Demonstrates sound knowledge bases and actions in the decision making process for designated patient populations.
  • 16.10. Documents program specific outcomes.
  • 16.11. Applies professional nursing skills in the provision of preventive health maintenance and/or treatment of illness
  • 16.12. Works independently to assess and evaluate understanding of disease process, treatment plan and/or lifestyle changes.
  • 16.13. Facilitates interdisciplinary communication.
  • 16.14. Assess learning needs of patient and significant other to support the patient through the care continuum.
  • 16.15. Provides general patient assessments.

    Other information:


    BSN required. RN license required in the State of CT.


    3-5 years clinical experience and Care Coordination/Case Management experience.
    Evidence of essential leadership, advocacy, communication, education and counseling, and resource research skills


    Current RN licensure in the State of Connecticut.


    *Core philosophy or values consistent with a family-centered approach to care
    *Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs
    *Demonstrates professional, appropriate, effective and tactful written, verbal, and nonverbal communication with patients, families, medical staff, colleagues, vendors, and other departments throughout the continuum of care to promote continuity of care and services and enhance clinic image.
    *Demonstrates positive professional customer service being respectful of all patients, coworkers and providers.
    *Demonstrates a positive attitude by smiling and being courteous to all patients, coworkers and providers, making every effort to be non-judgmental with comments and conversation.
    *Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations.
    *Participates in orientation and staff development activities as requested.
    *Strong interpersonal and leadership skills.
    *Proactively acts as patient advocate, responding with empathy and respect to resolve patient concerns and recognizes opportunities for improvement through patient concerns.
    *Complies with dress code and strives to act professionally in words and actions at all times.
    *Participates effectively as a team member in the clinic being accountable, helpful and welcoming to co -workers, providers and patients.
    *Proactively continues to educate self to provide quality care and improve professional skills.
    *Demonstrates effective teaching techniques, applying adult learning principles.
    *Demonstrates ability to coordinate appropriate educational materials for patients and their support systems.
    *Valid Driver?s license.
    *Must be able to travel to various delivery network locations and patient home visits.

    Accountable for coordinating the care of up to 150+ patients, representing in excess of $4 million in total healthcare spend per annum. Holds other members of the health care team accountable for their role in care processes across the continuum of care, focusing on the ambulatory / outpatient setting. Ensures that patients are progressing along critical paths in accordance with established clinical and financial outcomes; intervenes to manage barriers to care and has the authority to cross departmental lines. Accountable for analyzing and identifying variances and participating in implementing system and practice changes to enhance the efficiency and effectiveness of all efforts related to care delivery and coordination. Accountable for ensuring high quality patient care that is coordinated, efficient, and efficacious and supports desired clinical and financial outcomes.

    Must possess extensive clinical expertise to be recognized as a credible clinician by physician and other members of the team. Demonstrated ability to understand and anticipate the impact of practice and system issues on efficiency of care and cost of care. Must be able to negotiate with all members of the team and other departments to expedite care and services. Must be knowledgeable about the research process and the ability to utilize as well as conduct research. Will be responsible for the development of clinical pathways in collaboration with the health care team members; must be able to negotiate differences in perspectives and treatment modalities among clinicians to achieve consensus as to the plan of care. Works with individual and groups of physicians to help them understand opportunities to change patterns of practice and clinical resource management.

    MMR is required. Varivax (chicken pox vaccine) or evidence of prior chicken pox is required. Hepatitis B (or signed declination) is required for those with potential exposure to blood/body fluids.
    Tdap and influenza vaccination are strongly encouraged.

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    Job Info

    Job: 4633

    Department: Clinical Integration
    Category: Nursing-staff
    Status: Full Time
    Shift: DAYS
    Hours: 40.00

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