Care Coordinator | Heart Failure Clinic

Summary

Reports to the Director or Executive Director. Coordinates and manages outcomes of a specific patient population to facilitate achievement of quality, service, and cost.

Assigned to a patient caseload during the entire episode of care; from inpatient setting to ensuring smooth transitioning of care to post-acute care settings.

Works collaboratively with other Care Coordinators and interdisciplinary staff, internal and external to the organization.

Prepares summaries, reports, and profiles. Identifies and evaluates patient and family educational needs, provides assistance and support for cardiovascular patients and families.

Establishes and facilitates effective relationships with physicians, staff, patients and families.

MISSION, VALUES and SERVICE GOALS

• MISSION : We deliver outstanding care, inspire health, and connect with heart.
• VALUES : Trust. Respect. Integrity. Compassion.
• SERVICE GOALS : Personally connect. Keep everyone informed. Be on their team.

Coordinates patient care within established case loads throughout the entire continuum of care, spanning each area in which care is provided by :

Networking with physicians and other health care providers to assure effective implementation of patients' plans of care and establishment of desired patient outcomes.

Assisting physician as liaison between family and inter-disciplinary team by interpreting the plan of care to patients, families, and other members of the health care team.

Monitoring patient care and concurrently tracking variances. Referring variance trends to Director / Executive Director or appropriate physician reviewer for review and action.

Assisting with discharge by assuring coordination of community services, follow-up care, and education. Reviewing patient medical records to monitor completeness and accuracy, including medical issues not addressed prior to discharge.

Coordinating the gathering and reporting of patient outcome information post discharge. Conducting health screenings and educational offerings in the community.

Participates in continuous quality improvement by :

Compiling and analyzing data to generate reports which accurately represent utilization trends and patterns. Making recommendations to appropriate committees to improve overall quality of patient care.

Preparing summaries and reports for review by the Medical Director and the Director / Executive Director and the Quality Management Department.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by :

Completing other job-related assignments and projects as directed.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements :

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license / certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position / department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Commitment to Beacon's six-point Operating System, referred to as The Beacon Way :

• Leverage innovation everywhere.
• Cultivate human talent.
• Embrace performance improvement.
• Build greatness through accountability.
• Use information to improve and advance.
• Communicate clearly and continuously.

Education and Experience

The level of knowledge, skills and abilities indicated below are normally acquired through the successful completion of a Bachelor's Degree in Nursing, Dietetics / Nutrition or related area.

A Master's degree is preferred. Licensure as a Registered Nurse in the State of Indiana, minimum two years related clinical experience and experience in problem-solving and / or conflict-management processes in a health care setting required.

Knowledge & Skills

• Requires thorough knowledge of clinical care practices, education / teaching, procedures and techniques required to meet targeted patient population.
• Requires working knowledge of research methodology.
• Demonstrates effective analytical and problem-solving skills.
• Demonstrates proficiency in nursing or Dietetics clinical assessment skills.
• Demonstrates clear, effective communication skills, including verbal, written, and listening skills.
• Demonstrates well developed interpersonal skills necessary to promote and maintain cooperative, courteous, and sincere relationships with patients, family members, physicians, staff, and the public.
• Requires ability to independently prioritize and organize work activities and work effectively under pressure.
• Requires ability to identify and utilize appropriate resources.
• Demonstrates computer literacy and the ability to effectively use word processing, spreadsheet and presentation software.

Working Conditions

• Works in various environments including patient care areas with frequent changes in job demands.
• At risk for occupational exposure to blood borne pathogens.
• Mentally tasking at times due to need to prioritize, responding to changing patient / unit needs, unpredictable census and acuity.

Physical Demands

Requires the physical ability and stamina (i.e. to walk / stand for prolonged periods of time, push carts / wheelchairs up to 50 pounds, to position / lift patients at a maximum of 35 pounds unassisted, over 35 pounds requires assistance, provide CPR, etc.

to perform the essential functions of the position.