Job Description

Responsible for direction of patient care in the ambulatory care setting. Consults with staff, physicians and Director of Nursing on nursing problems and interpretation of SCHS policies to ensure patient needs are met. Maintains performance improvement activities within the department and participates in CQI activities. Assist Care Manager, providers and staff in the coordination of care of the patient population. This care coordination includes: Assisting patients with establishing appointments outside of the patient centered medical home, sends referrals, establishes co-management agreements and tracks the course of the patients care to ensure proper follow up and that any barriers to care are eliminated.

DUTIES AND RESPONSIBILITIES:

• Participation in care team and the coordination of patient care according to SCHS policies and procedures.
• Execution and tracking all patient testing and referrals for assigned location in accordance with the policies and procedures of SCHS.
• Executes co-management agreements with specialist for patients that require long term treatment.
• Education of the patient population about community resources and ensures proper coordination with Medical Director, providers, staff and outreach workers to eliminate barriers to care for the patient population.
• Stays up to date on community resources that are available to patients to promote holistic health and promote patient involvement in plan of care.
• Effectively participates in daily huddle for care coordination and continuity.
• Assist patients with in house referrals within SCHS.
• Manages patient testing and notifies provider of lab/ x-ray results, including flagging the provider for abnormal test results and communicating provider instructions to the patient.
• Effectively builds and manages partnerships/relationships with outside sources to promote continuity of care.
• Coordinates and directs patient care to ensure patients’ needs are met and SCHS policy is followed.
• Communicates with local hospitals, clinics, specialist and insurance plans to ensure proper follow up after a hospital admission or Emergency Department visit.
• Contacts patients in pre-visit preparation before upcoming appointments.
• Follows up with patients/families who have not kept important appointments.
• Assist providers in promotion of patient self-management including self-management tools.
• Other reasonable duties as assigned

Requirements

Regulatory Requirements:

• Graduate of an accredited school of nursing with care management/ambulatory care experience preferred.
• Current nursing license within the state of practice preferred.
• Current BLS certification

Language Skills:

• Able to communicate effectively in English, both verbally and in writing.
• Additional languages preferred.

Skills:

• Basic computer knowledge.

Physical Demands:

• For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.