Lead Care Coordination (INTERNAL ONLY)

Job Description

Job Description

Core Value Commitment :

In common mission, our teams work together with our patients at think. We strive to continuously improve. We value one another’s diversity of talent, experience, and perspective. We each contribute to something bigger than ourselves while promoting integrity, belonging, and collaboration.

Job Summary :

The Care Coordination Lead is responsible for coordinating the care of all Think patients. Serves as the main conduit of communication for the Care Coordination Team. This role is assigned to the entire Care Coordination Department and works closely with Care Coordination Manager to provide the best personalized care to the patients ensuring that the appropriate levels of healthcare resources are utilized. This role also supports staff in creating a patient-specific plans of care for patients enrolled in a specific value-based program. The Care Coordination Lead will assist each staff member in executing their plan of care to improve health outcomes and satisfaction and to decrease healthcare costs.

Essential Job Functions :

• Daily nursing assignments and distributes provider coverage as needed.
• Phone and chart audits as needed,
• Collaborate with the providers.
• Responsible for training and onboarding new employees.
• Assist the manager with training / educating new policies, procedures, and processes.
• Assess the medical, social, and psychological needs of patients.
• Create patient-specific care plans and identify which resources to deploy for each patient.
• Provide education on various healthcare conditions to improve health outcomes for patients and families.
• Maintain detailed documentation in patients’ Electronic Health Record
• Coordinate with various service providers to ensure the fulfillment of the patients’ needs.
• Correspond with patients via phone using internal protocols, to provide appropriate recommendations for needed care.
• Collaborate with providers in planning routine or acute visits and obtain the required information before the visit.
• Review outside clinical data, e.g., labs, x-rays, and consultation reports, and delegate to the proper team member.
• Coordinate patient specific care with nursing homes, home healthcare agencies, and hospitals as needed.
• Make outgoing calls to complete transition of care visits and schedule appointments as needed.
• Delegate tasks appropriately to LPN, MA, and other unlicensed staff.
• Communicate or address process improvement opportunities / errors with staff as needed.
• Communicate department needs and issues to manager.
• Ensure appropriate staffing daily and make necessary adjustments independently to ensure provider coverage.
• Organize and assign duties and tasks to others as appropriate.
• Organize and manage Allscripts message boxes and Cisco Finesse team performance to enhance productivity of team.
• Support staff in creating and executing patient-specific plans for their value-based programs.

Knowledge, Skills & Abilities :

EDUCATION & Experience :

Associate Degree in Nursing (ADN)required, Bachelor of Science in Nursing (BSN) preferred. Active Nursing License in the State of Nebraska required. Active BLS / CPR certification required. A minimum of two (2) years of nursing experience required. Bachelor of Science in Nursing (BSN) and two (2) years of experience in case / care management working with adult patients preferred. One (1) year of experience in a triage nursing setting preferred.

Think Whole Person is an Equal Opportunity Employer