Kalispell

RN Primary Care Coordinator - CPC+ KMO

US-MT-Kalispell
Requisition ID
2017-3133
# of Openings
1
Category
Nursing - Clinic
Pay Period Status
40
Shift
Days
Schedule
dayshift, flexible hours

Overview

The Nurse Primary Care Coordinator offers individualized assistance to patients, families, and caregivers to help overcome healthcare system barriers. Facilitates communication, coordinates services, addresses barriers, provides education, and promotes optimal allocation of resources while balancing clinical quality and cost management. Assists patients and their families as they transition through multiple healthcare settings while providing chronic care and high risk care management.

Responsibilities

  1. *Assesses patient needs upon initial encounter and periodically throughout navigation. Matches unmet needs with appropriate services, referrals and support services, such as dietitians, providers, social work, pharmacy, and financial services. Acts as a liaison between the patients, families, caregivers and the providers to optimize patient outcomes.
  2. *Identifies high risk patients who would benefit from chronic care management and works collaboratively with the primary care provider, patient, and family to develop an individualized patient-centered plan of care.
  3. *Participates in coordination of the plan of care with the multidisciplinary team, promoting timely follow-up on treatment. Facilitates timely scheduling of appointments, referrals, diagnostic testing, and procedures to expedite the plan of care and to promote continuity and quality care.
  4. *Utilizes appropriate assessment tools (e.g., PHQ2/9, mini cog, pain scale, etc.) to promote a consistent, holistic plan of care. Provides psychosocial support to and facilitates appropriate referrals for patients, families, and caregivers, especially during periods of high emotional stress and anxiety.
  5. *Provides and reinforces education to patients, families, and caregivers about chronic disease process, discharge teaching/instructions, new diagnosis, and medications.
  6. *Builds therapeutic and trusting relationships with patients, families, and caregivers through effective communication and listening skills. Utilizes motivational interviewing techniques to assist patients in meeting their goals and managing their chronic disease.
  7. *Facilitates communication among members of the multidisciplinary primary care team to prevent fragmented or delayed care that could adversely affect patient outcomes.
  8. *Supports a smooth transition of care for patients from one level of care to another. Provides acute care, skilled nursing facility, and ER follow up.
  9. *Participates in the tracking of metrics and patient outcomes, in collaboration with administration, to document and evaluate outcomes of the navigation program. Focuses on prevention measures consistent with established guidelines and care process models and works toward continuously improving quality metrics and closing care gaps.
  10. *Collaborates with the care coordination team to develop and improve workflows and protocols for primary care that ensure hospital, ER, and community resource follow-up.
  11. *Demonstrates effective communication with peers, members of the multidisciplinary healthcare team, and community organizations and resources.
  12. *Works collaboratively with fellow Care Coordinators and other members of the care coordination team

Qualifications

  1. Current Montana RN license, BSL certification required.
  2. Bachelor’s Degree in Nursing preferred, or must be able to obtain within five (5) years of employment.
  3. Possess and maintain computer skills to include working knowledge of Word, Outlook, Excel, PowerPoint, Access and ability to learn other software as needed. Knowledge of electronic health records preferred.
  4. Must function with a high degree of autonomy, communication and interpersonal skill. Must understand the health care continuum and have the ability to solve complex problems.
  5. Demonstrated ability to work collaboratively with multidisciplinary medical home care teams. Knowledge of professional practice standards, regulatory requirements, and systems operations required.
  6. Nursing experience in a variety of care settings (Outpatient Clinic, SNF, Home Health, and Acute Care) preferred. Knowledge of NCQA and the Medical Home care model preferred.
  7. Ability to evaluate clinical outcomes across a variety of primary care settings and familiarity with diabetes and lipid management, including dietary assessment preferred.

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