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, Livingwell: Reporting to the Manager, Care Coordination in collaboration with physicians, staff and other healthcare professionals, is responsible for the overall plan of patient care for a specific employee population of Yale New Haven Health System and their dependents. Coordinates appropriate resources to facilitate and ensure the patient's progress through the continuum of care. Ensures patients have a primary care medical home and care coordination across the heath care continuum. Actively participates in the quality review process and assures continual improvement of nursing 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. 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 on the employee health pilot, NEMG staff, PM staff, Occupational Health, 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. Develops the overall plan of care/guidelines and communicates plan to members of the patient care team.
- 1.1 Reviews clinical records to obtain demographic and financial information and assesses physiological needs appropriate to plan of care as evidenced by documentation in patient care record.
- 2. Provides direct/indirect care to select patients and families.
- 2.1 Assess psychosocial needs of patients and families and provides counseling and/or referrals as evidenced by documentation in patient care record.
- 3. Utilizes relevant research findings to improve patient outcomes.
- 3.1 Integrates relevant research findings into practice as evidenced by observation and feedback.
- 4. Synthesizes data from a variety of sources and makes appropriate clinical decisions. Responsible for the management of data.
- 4.1 Assuring database is kept up to date.
- 5. Conducts pre-visit chart review of patients.
- 5.1 Identification of all needed preventive health maintenance, immunizations, and chronic disease interventions.
- 6. In collaboration with the Care Team, works with patients and families on Self-Management Support.
- 6.1 Setting short and long-term goals for self-management of chronic disease.
- 7. Coordination of Care across the care continuum.
- 7.1 Assists as liaison with patients and their families to physicians, clinical staff, and other departments.
- 8. Involvement in QI activities.
- 8.1 Actively participates/coordinates committees as needed/requested, i.e. Performance Improvement Teams.
- 9. General RN Duties.
- 9.1 Types correspondence (memos and letters), statistical forms and procedures and is able to maintain complete patient records while keeping complete patient confidentiality.
RN required. BSN required. Current RN licensure in the State of Connecticut.
3-5 years clinical experience and Care Coordination/Case Management experience.
Current RN licensure in the State of Connecticut.
*Demonstrates professional, appropriate, effective and tactful written, verbal, and nonverbal communication with patient, 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 Drivers license.
*Must be able to travel to various delivery network locations and patient home visits.