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.
Regional Care Coordinator, Patient-Centered Medical Home: Reports to the Program Manager, PCMH, and works in collaboration with physicians, PM staff, Patient Navigators and other healthcare professionals to develop, implement, evaluate and revise the delivery of care coordination services to the NEMG patient population determined to be high risk. The Regional Care Coordinator will be assigned to the NEMG primary care/family practices within a determined geographic region. This position will be responsible for collaborating directly with providers, vendors, and community agencies within the specified geographic area in creating consistent and coordinated delivery of high quality health care services. Nursing actions will be directed toward the goals of prevention, assessment, risk reduction, and health status improvement for high risk patient populations. Nursing activities include, but are not limited to systematic analysis of health data, care plan development, health education and advocacy, and collaborating with system and community partners to promote the health of a population. The Regional Care Coordinator works from within the context of a patient-centered, 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 wellbeing. 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 specified practices. 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.
Responsibilities: 1. Demonstrate and apply knowledge of the philosophy/principles of comprehensive, community based, patient-centered, developmentally appropriate, culturally sensitive care coordination services. 2. Provide care coordination, referral and follow-up to individuals and families who are members of a vulnerable population and/or high risk groups. Evaluates outcomes, effectiveness of plan, and makes changes as necessary on micro and macro levels. 3. Manage a caseload of high-risk patients to assure coordination of services based on NCQA Standards and Guidelines for PCMH. 4. Engage individuals and families in a plan of care that addresses their identified health deficits and issues. Provide education and counseling to individuals, families and groups that are adapted to their unique needs, lifestyle, cultural and socio-economic situation. 5. Document patient assessment and intervention data in medical records. Use established medical record forms, databases, and documentation practices. 6. Collaborate in development and delivery of programs and activities for individuals, families and population groups that promote health and prevent disease. 7. Collaborate in the development of and contributes to individual, team, and department quality improvement and evaluation activities 8. Advocate on behalf of vulnerable individuals and populations; participates in assessing and evaluating health care services to ensure that people are informed of available programs and services and are assisted in the utilization of those services. 9. Contribute to a work environment that fosters ongoing educational experiences for colleagues, healthcare professionals and members of the community. 10. Utilizing the disease registries and payor-supplied data, participates in the analysis of data to identify trends, health problems, environmental health hazards, and social and economic conditions that adversely affect patients' health. 11. Collaborate in developing a work environment where continuous quality improvements in practice are pursued. 12. Assume responsibility for own professional growth and development by pursuing education, participating in professional committees and workgroups. 13. Collaborate in the development of evidence-based nursing practices. 14. Utilize appropriate methods for interacting effectively and professionally with persons of all ages and from diverse cultural, socioeconomic, educational, racial and ethnic backgrounds, sexual orientations, lifestyles and physical abilities. 15. Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up and integration of information into the care plan. 16. Coordinate efforts to gain patient and family feedback regarding their experiences of health care (focus groups, surveys, and other means); participate in interventions which address articulated needs. 17. General RN Duties: 17.1. Types correspondence (memos and letters), statistical forms and procedures and is able to maintain complete patient records while keeping complete patient confidentiality. 17.2. Maintains confidentiality of patient, personnel, and institutional information. 17.3. Demonstrates effective organizational skills. 17.4. Demonstrates current level of knowledge of various payor regulations. 17.5. Demonstrates clinical leadership as evidenced by various payor regulations. 17.6. 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. 17.7. Accurately and legibly documents all patient interactions in the patient record. 17.8. Demonstrates self-directed learning needs and seeks ways to meet own professional development. 17.9. Demonstrates sound knowledge bases and actions in the decision making process for designated patient populations. 17.10. Documents program specific outcomes. 17.11. Applies professional nursing skills in the provision of preventive health maintenance and/or treatment of illness. 17.12. Works independently to assess and evaluate understanding of disease process, treatment plan and/or lifestyle changes. 17.13. Facilitates interdisciplinary communication. 17.14. Assesses learning needs of patient and significant other to support the patient through the care continuum. 17.15. Provides general patient assessments.
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 patient-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 clinical 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 nonjudgmental 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 coworkers, 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.
Accountable for coordinating the care of a panel of patients within a specified geographic region. Holds other members of the health care team accountable for their role in care processes across the continuum of care, focusing on the outpatient/ambulatory setting. Ensures that patients are progressing along critical pathways 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 physicians and other members of the health care 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 individuals 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.