Job Description

About North Country Healthcare (NCH):

North Country Healthcare is a non-profit affiliation of four medical facilities, Androscoggin Valley Hospital, North Country Home Health & Hospice Agency, Upper Connecticut Valley Hospital, and Weeks Medical Center, located in the White Mountains Region of New Hampshire. NCH includes numerous physicians and medical providers at multiple locations. This leading comprehensive healthcare network which employs hundreds of highly trained individuals delivers integrated patient care through three community hospitals, specialty clinics, and home health and hospice services. NCH remains committed to the health and well-being of the communities we serve. As a leader in a management position this role emphasizes advancing High-Reliability Organization (HRO) principles, embedding a culture of safety, accountability, and consistent high performance.

The Inpatient Care Coordinator is an integral member of the Inpatient Care Team. They work closely with both inpatient and outpatient team members as well as community partners to assist patients in overcoming barriers as they navigate the healthcare system and manage their health and wellness needs. The Inpatient Care Coordinator supports patients by assessing needs, developing individualized care plans, and arranging appropriate post-discharge services. Collaborating with the interdisciplinary team, the Inpatient Care Coordinator ensures that plans of care are effectively executed to promote safe, timely, and appropriate discharges or transitions to the next level of care for Weeks Medical Center patients.

ESSENTIAL QUALIFICATIONS

Education:

• High School Diploma
• Associate's Degree in health health-related field (i.e. human services) or Medical Assistant certification preferred

Licensure:

• Basic Life Support (BLS) (for clinical staff), or Heartsaver CPR AED (for nonclinical staff), and renewal on a regular basis, with up to a three-month grace period after the expiration date

Skills:

• Computer literate: knowledge of Microsoft Office (Word, Excel)
• Knowledge of medical terminology preferred
• Compassionate and able to relate to different clients with various needs
• Motivational to encourage clients to follow their care plans
• Strong verbal and written communication skills to explain to clients, family members, friends, and professionals the case and care plan and maintain good case records
• Critical thinking and problem-solving skills to determine the best care plan for each client after assessing clients, analyzing notes from healthcare and social workers
• Flexibility to change care plans if they are not getting the best results
• Organization to manage several different cases at once

Work Experience:

• Case management experience in a medical setting or home care environment preferred

ESSENTIAL FUNCTIONS:

1. Develop discharge plan on admission that will enable for smooth transition of care
2. Meet with patients and families regularly for implementation of discharge plan
3. Meet with other departments as needed for patient care and transition
4. Work closely with hospitalist and interdepartmental team members to ensure the proper steps are being taken towards the discharge plan for each patient
5. Document ongoing case management activities in the electronic health record
6. Coordinate patient care conference (family meetings) when necessary to ensure all disciplines are working together to gain optimal outcomes for the hospital stay
7. Send and manage referrals for patients for discharge services including but, not limited to, Home Health/Hospice referrals, transportation, CAP, Meals on Wheels, CCM, and Community Health Workers (CHW)
8. Assist patients with completion of Advanced Directives
9. Serve as a point of contact, advocate, and resource for patient, family, care team, payers, and community resources
10. Promote healthy behaviors in all populations and ensure navigation assistance with community resources
11. Works closely with care management and staff from other facilities to coordinate transfers both from outside facilities to Weeks and from Weeks to other facilities
12. Serves as an advocate and informational/educational resource for patients and families
13. Assesses patient and family unmet needs and refers to other resources as appropriate
14. Attend meetings as requested i.e. readmission, IDT, and staff meeting

1. Evaluate the patient's medical status to determine specific DME needs (e.g., mobility aids, respiratory equipment) as ordered by physicians

NON-ESSENTIAL FUNCTIONS

1. Performs additional duties as assigned.
2. Adheres to facility Values, Service Excellence and Standards of Excellence.