Nurse Care Coordinator

Health NavigatorUnder the general supervision of the Manager of Population Health & Care Coordination, is responsible for coordinating clinical care; educating; advocating; and assisting as the health navigator for patients in the Huggins Hospital Medical Practices. In addition, this position is responsible for assistance with data collection, analysis and reporting.Patient Centered Care:Participates in Patient-Centered team meetingsParticipates in data collections, health outcomes reporting, clinical audits, and programmatic evaluation related to Patient-Centered Care Coordination initiativesDirect Patient Care:Facilitates health and disease management educationSupports patient self-management of disease and behavior modification interventions.Provides comprehensive preventative wellness exams 3: WeightCare Coordination:Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visitsIn collaboration with PCP, manages high risk patient care, including management of patients with multiple comorbidities or those at high risk for readmission to a hospital settingPromotes clear communication amongst a care team and with treating clinicians by ensuring awareness regarding patient care plansPopulation Health & Quality Improvement:Works with the Population Health Manager and IT on care opportunity reports to identify and address preventative careWorks to maximize opportunities for quality incentive payments from governmental and private payers related to population health and chronic care managementProvides data analytics and reporting for population health and disease management.Participates in quality review, performance improvement, and medical practice patient satisfaction improvement initiativesOrganizational Expectations:Attendance: Attendance is an essential job function; employee comes to work daily, on time, and completes scheduled shiftHIPAA: facilitates to maintain patient confidentialityInternal communication: contributes to positive team performance and a culture of service excellence through effective communication, active listening, and respectInterpersonal relationships: maintains appropriate interpersonal relationships with staff, patients, and visitors at all times. Works as a team member with other departments.Safety: Practices workplace safety dailyEmployee Engagement:Actively participates in all hospital Service Excellence initiatives and trainingsAttends and participates in a minimum of 50% department staff meetings and signs off on review of 100% department staff meeting minutesCompletes all required annual education on or before the due dateKnowledge Skills and Abilities: Individuals must possess these knowledge, skills, and abilities or be able to explain and demonstrate that they can perform the primary functions of the job, with or without a reasonable accommodation, using some combination of skills and abilities and possess the necessary physical requirements, with or without a reasonable accommodation, to safely perform the essential functions of the job.Minimal physical effort required with occasional light lifting to a maximum of 25 pounds; stooping; and pick, pinch, type, or otherwise work primarily with fingersAbility to effectively manage considerable mental stressAbility to express or exchange ideas by means of the spoken wordAbility to receive detailed information through oral communicationAbility to communicate effectively with co-workers and convey information in a clear, concise and accurate mannerFamiliarity with computer and other business machinesQualifications:Completion of RN or LPN program One year office experience preferredActive NH RN or LPN License BLS RequiredEqual Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.