Position Summary: This position serves complex chronic care patients by coordinating care management, patient-centered, cost effective care to specifically identified patient populations. She/he will access, analyze, customize, coordinate and communicate the patient’s plan of care and collaborate with providers and all members of the multi-disciplinary health care team to manage and facilitate patient registries and care delivery appointments and service. Actively participates in Patient Centered Medical Home workflows and QI processes.
Essential Duties and Responsibilities:
CARE COORDINATION: Assists patients to navigate through the healthcare system by acting as a patient advocate. Facilitates patient education and access to healthcare and community resources. Coordinates continuity of patient care with external healthcare organizations and facilities, including the following transitions of care: hospital admission, discharge, and referrals from the primary care provider to specialty care providers. Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ED visits. Promotes clear communication among clinical provider staff by ensuring consensus and updates regarding patient care plans.
ASSESSMENT AND PLANNING: Monitors patient conditions monthly or more frequently as indicated. Creates an evidenced-based comprehensive action plan for each patient. Manages high-risk patient care, including management of patients with multiple co-morbidities and/or high risk for hospital readmission. Support patient self-management. Manages patient registries to ensure compliance, timely lab and medication management and patient appointment scheduling.
DATA COLLECTION AND REPORTING: Responsible for the collection, reporting, and analysis of clinical data. Evaluates clinical care and utilization of resources.
DOCUMENTATION: Documents patient care information in an accurate, concise, and timely manner. Competent in information management in both written and electronic documentation systems.
PARTICIPATION: Actively participates in staff meetings, and other meetings as appropriate. Actively participates in professional, departmental, and organizational education and competencies. Actively assists others in transitioning and applying knowledge to the clinical and operational setting.
Promotes and role models collaborative practice relationships with all
healthcare professionals. Recognizes the role that the cultural diversity of patients and their families, employees, medical staff, volunteers and community members plays in achieving productive and positive relationships.
Safeguards all forms (Electronic, written and oral) of confidential information as it relates to patients, their families, medical staff and employees. Is aware of and compliant with organizational polices regarding HIPPA, Fraud and Abuse, Conflict of Interest and the Code of Conduct.
Education: Graduate of an accredited school of nursing. Master’s degree from an accredited college or university with major course work in public health or a closely related field preferred. Emphasis on program planning and development preferred.
Required Licensure and/or Certification: Licensure as a Licensed Practical Nurse or Registered Nurse in the States of Illinois a plus.
Ability to prioritize, organize and carry out work assignments with minimal supervision. A minimum of three (2) years relevant clinical experience is required. Must possess excellent computer and customer service skills with a caring approach to care.
Proven ability to effectively communicate, verbally & in writing, with all levels of staff personnel.
Team-oriented and able to work collaboratively with staff.
Strong problem-solving and time-management skills.
Ability to work independently in a fast-paced, medical office environment with frequent interruptions, public contact, and occasional crisis situations.
Ability to maintain strict confidentiality with sensitive medical information and foster an ethical work environment.
Ability to understand and respond effectively and with sensitivity to special populations served by NNHSC. Special populations include, but are not limited to, those defined by race, ethnicity, language, age, sex, sexual orientation, economic standing, disability status, homelessness, and the uninsured.
About Near North Health Service Corporation
Near North Health Service Corporation is an Equal Opportunity Employer. The Mission of Near North Health Service Corporation (NNHSC) is to provide access to high quality health care and to improve the health and well-being of the diverse populations and communities we serve. We are a culturally sensitive, patient centered community health center that empowers individuals through education and health prevention, regardless of one’s ability to pay.