Memorial Regional Health
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Complex Care Coordinator - Population Health
at Memorial Regional Health
M-F Business Hours
- Contact: Ashly Shipman
- Tel: (970)826-3172
- Fax: (970)826-3179
- Email: firstname.lastname@example.org
- Address: 750 Hospital Loop Craig, CO 81625
Position Purpose: The Complex Care Coordinator serves as a member of the team that provides care coordination services to high-risk and at-risk patients with a variety of existing chronic or episodic conditions, employing a continuity of care approach to support and educate patients to achieve positive and improved outcomes. The Complex Care Coordinator, as a member of the Population Health Management department, will help fulfill the Memorial Regional Health (MRH) mission of improving the quality of life for the communities we serve, with patient-centered care and service excellence.
Essential Functions and Basic Duties:
o Collaborate with Providers, perform chart reviews, and utilize clinical reports from Electronic Health Records to identify patients who require or would benefit from care coordination services.
o Ability to create and evaluate reports to identify and stratify patient risk factors based on identified criteria.
o Able to identify patients at risk for abuse, depression, falls, or other conditions. Follow the proper procedures for reporting.
o Adhere to MRH standardized processes and procedures that create and support efficient and effective continuity of care practices for patients served by the care coordination team.
o Participate in the development of standardized processes and procedures that create and support efficient and effective continuity of care practices for patients served by the care coordination team.
o Participate in "outside the box" thinking and approaches for patients that could benefit from non-traditional treatment plans.
o Collaborate with the Patients and Family Members, Providers, Nurses, and Care Coordinators in the development of care plans; document and implement plans in cooperation with the care team.
o Ensure all care coordination patients follow their care plan criteria and adhere to their care plan contract.
o Provide patient education and involve patients and family members in decision-making to achieve maximum wellness. Assist patients in setting goals for healthcare self-management, track progress, provide support, encouragement, and corrective measures as appropriate to achieve positive long-term sustainable health outcomes.
o Track and monitor referrals; assist in scheduling appointments; follow-up on appointments and track results; provide patient education; connect patients with resources (MRH-based, community, other providers, etc.); address care plan non-compliance and missed appointments; facilitate medication reconciliation.
o Assess and address barriers to care, including but not limited to: pre-authorizations, ability to pay, communication (non-English speakers, etc.), transportation, outside referrals.
o Conduct and document after-visit summaries (in-person; via phone or email; etc.) to ensure follow-up care is occurring and patient needs are being met.
o Be available identify and respond to emergent and urgent patient calls requiring immediate care team intervention.
o Serve as a liaison between clinic, hospital, and emergency department personnel, imaging, lab, dietary, pharmacy, specialty providers, patient billing advocates, third-party payers, community resources, and other agencies as needed in support of care coordination activities.
o Establish and maintain excellent working relationships with care coordination team members, patients and their families, providers and other medical personnel, community partners, other MRH staff, with an emphasis on building strong teams, improving processes, and providing excellent customer (patient) service.
o Identify and maintain a network of community resources and ancillary services (MRH-based and external); participate in patient education and refer patients to appropriate resources.
o Utilize and contribute to the Care Coordination Resource Directory, sharing information with team members, and contributing to departmental best practices and information exchanges.
o Connect patients with limited or no ability to pay with MRH Patient Billing Advocates for support and resources.
o Ensure patient interactions are properly charted in the patient electronic health record (correct coding to ensure accurate payment/reimbursement to MRH.)
o Ensure work is compliant with MRH policies, procedures, and quality measures.
o Submit quality reporting data to governing agencies for compliance purposes, as assigned by the Director of Population Health Management.
o Attend meetings to stay apprised of organizational communications. Notify the Director of Population Health Management or other senior leadership of staff concerns; participate in resolutions.
o Complete reports in a timely manner.
o Contribute to and participate in a collaborative, supportive environment among care coordination team members.
o Demonstrates 100% commitment to performing according to the CHOICE values of MRH and representing the organization in a positive and professional manner.
o Establishes and maintains effective communication and good working relationships with all co?workers.
o Adheres to MRH and department dress code policies and procedures.
o Utilizes initiative; strives to maintain steady level of productivity; self-motivated; manages activity and time.
o Completes annual education, training, in-service, and certification requirements; attends departmental staff meetings or reads meeting minutes.
o Maintains regulatory requirements.
o Maintains patient confidentiality at all times.
o Reports to work on time and as scheduled; completes work within designated times.
o Actively participates in departmental and facility performance improvement and continuous quality improvement activities.
o Strives to ensure continual compliance with departmental, hospital, state and federal regulations and policies.
o Follows policies and procedures for infection control, safety, and risk management to ensure a safe environment for patients, public and staff.
o Bachelor's degree in nursing or other healthcare-related field required
o Registered Nurse license in the State of Colorado, preferred but not required
o Minimum five (5) years' experience in patient care setting (inpatient and/or outpatient)
o Demonstrated success working in an integrated environment and working within a cross-functional team.
o Outstanding written and verbal communication, documentation, and presentation skills.
o Able to apply National Patient Safety goals to care and documentation.
o Knowledge of medical practices and patient care.
o Knowledge of patient examinations, diagnostic and treatment procedures.
o Ability to work with a Healthcare Electronic Medical Record to review patient data and run reports.
o Ability to communicate effectively, both in writing and orally.
o Ability to establish and maintain effective working relationships with employees at all levels throughout the institution.
o Ability to interpret, adapt, and apply guidelines and protocols.
o Ability to identify and resolve problems in a proactive, collaborative manner.
o Outstanding customer service skills.
o Demonstrated commitment and leadership ability to advance diversity and inclusion.
o Strong analytical skills, critical thinking, attention to detail and accuracy, and strong customer service skills.
o Fax Machine
o Copy Machine
o Basic Office Equipment
Mandatory Training & Involvement:
- SWANK Education
- NIMS Training: IS-100Hcb and IS-700A
- Staff Meetings
- Infection Control
- Hazardous Materials
- CHOICE Values
- AIDET + P
- LEAN training
- Service Excellence
- Compliance Program Review
- Safety In-Service
- Annual Competencies
- ISO 9001