Job Summary: The Clinical Care Coordinator is responsible for coordinating screening and providing the intervention of patients with identified complex chronic care needs. Functions in the capacity of a connector between the patient’s needs and the resources provided by the care management program. Supports whole health outcomes and communicates progress to those in the healthcare organization as well as ensuring the patients receive the best possible care.
Essential Duties and Responsibilities:
1. Maintain patient care hours per week at designated site as determined by Chief Public Health Officer.
2. Provide consultation and academic support to residents and attending physicians in the areas of bio psycho social care coordination that may affect overall health outcomes including social determinants of health, substance use and mental health concerns.
3. Participate fully in relevant quality assurance and performance improvement measures.
4. Provide comprehensive consultation regarding disease management assessment and mental/behavioral health treatment options to established patients.
A. Assess patients’ and/or families’ bio-psycho-social situations that result in diagnostic conclusions that include development issues, family dynamics and stressors, and a DSM IV multi-axial diagnosis.
B. Develop and execute an individualized care plan (may include medication reconciliation) for high-moderate risk patients/family and other patients referred to you in collaboration with physician, nursing staff, other professional staff and input from patient.
C. Document data, assessment, care plan and expected outcome in electronic medical record.
D. Review and update care plan based on risk-determined calendar cycle (e.g. 30days for high risk and 60days for moderate risk).
5. Identify and follow-up on all referrals you have made to assure continuity of care and patient/family needs are met.
6. Complete disease specific education as necessary with patient and patient family.
7. Communication with providers and care team regarding patient progress and care needs.
8. Complete home visits, or visits to skilled nursing facility, or hospital as needed and determined by the care team.
9. Participate in individual and group supervision monthly.
10. Perform any crisis intervention, individual counseling, family counseling, advocacy that is needed for the patient.
11. Performs other duties as assigned.
• Graduate of an accredited school of nursing or social work.
• 2 – 3 years clinical experience preferred.
• 2 - 3 years EMR experience preferred.
• Constantly communicates with patients, families, and other healthcare providers. Must be able to exchange accurate information in these situations.
• Demonstrated skills in the designated and certified clinical area of practice arena and the ability to work and collaborate on a health care team.
• Demonstrated ability to effectively and efficiently handle a demanding workload involving multiple tasks.
1. Current and valid CPR certification.
2. Current and valid driver’s license.
3. Social Worker – LSW required (LCSW is not required).
4. LPN or RN – ASN, BSN or MSN required
Active State of Illinois LPN or RN license required
• Must be able to remain in a stationary position 50% of the time.
• Must be able to move around the clinic site 50% of the time.
• Constantly operates a computer, computer printer, copy machine, and telephone.
• Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
• Ability to move as needed to perform necessary nursing skills such as wound care, injections, and other procedures. Must be able to transport from one site to another.
• Must be able to cover other shifts as necessary.
1. Ability to read and write proficiently using the English language.
The mission of PCC is to improve health outcomes for the medically underserved community through the provision of high quality, affordable, and accessible primary health care and support services. Anchored with family medicine, we are committed to serving the needs of all people in all stages of life, while we continue to specialize in the delivery of comprehensive maternal and child health services to address this unmet need in our community.
PCC prides itself in providing a model work environment. PCC provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws.
For more information on PCC Community Wellness, please visit our Web site at http://www.pccwellness.org