Care Coordinator II

Description

Are you a compassionate and dedicated Registered Nurse looking to make a meaningful impact in a close-knit community? Klickitat Valley Health is seeking a skilled RN Care Coordinator to join our team in providing high-quality, patient-centered care. Situated in the heart of Goldendale, WA, our rural hospital and family medicine clinic serve as the cornerstone of health and wellness for our community.

GENERAL SUMMARY:

Care Coordination and Innovation is a constantly evolving program for KVH and for the state of Washington, which means that the Care Coordination leader must be able to think and work independently, creatively, productively, and in an environment with few established policies and procedures to guide their work.  This work will be complex (both broadly conceptual and tedious and detailed), requiring a mature, holistic approach in order to be successful.  The Care Coordinator is primarily responsible for coordinating and expediting care for patients attributed to the Accountable Care Organization and Medicaid affiliates; effectively communicating with patients, providers and community support organizations to coordinate and facilitate a comprehensive plan of care for patients; and facilitate a shared goal model within and across settings to achieve coordinated high-quality care that is patient/family centered.  Care Coordination plays a crucial role in assessing patient needs, providing medical advice, and coordinating care within the hospital and clinic setting. This position requires excellent clinical judgment, communication skills, and the ability to prioritize patient care effectively.

If you’re committed to fostering strong patient relationships, enhancing care coordination, and contributing to the health of a rural community, we’d love to hear from you!

Qualifications

Minimum Education, Training & Experience (includes licenses or certifications):

Education:

• Graduate of an accredited school of nursing with a minimum of an Associate’s Degree in Nursing. Bachelor’s degree preferred.

• Continuing education and/or specialized training in managed care or outpatient clinic operations preferred. 

• Ability to obtain certification in Annual Wellness Visits within six months of hire.    

Experience:

• Three (3) years of nursing experience providing direct patient care in the acute care, home health, or outpatient physician clinic environment with evidence of strength in areas of leadership, creativity, flexibility, self-direction, organization, problem-solving, communication, and multi-tasking.

• Experience using health care IT systems and data.

• Experience with community building, health professional education, and/or working with populations enrolled in subsidized health services.

• Experience creating and continuously improving processes and systems of care, including clinical care delivery and administrative functions supporting such care preferred.

• Document management skills to support work plan creation and maintenance, teaching, record keeping and, communication.

• Experience teaching others with a variety of learning and retention styles.

Skills/Knowledge/Abilities:

• Working knowledge of community/public health, patient care coordination and case management including clinical care processes and systems in the hospital (inpatient and emergency room), physician clinic, and home health settings. 

• Knowledge of health care delivery; ability to analyze, implement and evaluate health care delivery processes related to the Accountable Care Organization (ACO) and Medicaid affiliates. 

• Ability to cultivate effective partnerships and work in collaboration with providers, other health care professionals, caregivers, and patients. Strong leadership, facilitation, delegation, and coaching skills. 

• Intermediate to advanced skills in data mining, analysis and reporting. Proficient in the use of current technology, including Microsoft Office products (e.g. Excel). 

• Ability to develop processes and systems and to maintain accurate documentation and records.

• Professional and effective written and verbal communication skills. Ability to identify and employ communication strategies appropriate to the audience.

• Ability to work independently performing a wide variety of assignments that require the use of independent judgment, problem-solving, organization, and prioritization skills.

• Work plan creation and execution.

• Superior organizational ability.

• Ability to exercise discretion in confidential matters.

• High degree of accuracy.

• Excellent attention to detail.

Essential Functions/Responsibilities (but not limited to):

• Coordinates team-based care through effective partnerships with patients, their caregivers, and their providers. Communicates effectively with primary care providers, hospitals, specialists and post acute care facilities to schedule appointments and identify and fill gaps of care; facilitates access to appropriate primary and specialty providers as well as other care coordination team support specialists (e.g. Podiatry; Wound Care); follows-up to ensure patients follow through with their scheduled appointments; coordinates requests for care and provides timely communication to facilitate progress toward common goals.

• Provides a coordinated strategic approach to detect and effectively manage patients with chronic disease. Establishes an effective tracking system for identified patients. Coaches patients/families toward successful self-management of chronic disease; assesses patient and family’s unmet health and social needs; provides effective communications to improve health literacy; educates patient on availability of resources such as psycho-social support, treatment resources, family educational resources and financial assistance; monitors patient adherence to plan of care and progress toward goals.

• Serves as the point-of-contact, advocate, and informational resource for patient, family, care team, payers, and community resources. Facilitates and attends meetings between patient, family, care team, payers, and community resources, as needed. Proactively acts as patient advocate; responds with empathy and respect to resolve patient/family concerns.

• Conduct initial assessments of patients via phone or in person to determine the urgency of their medical needs and facilitate urgent medical issues or offer guidance to ensure patients receive appropriate care levels.

• Creates processes to effectively track, monitor, and report on participant and provider performance that includes data points such as cost per patient, diagnosis, risk factors, inpatient readmissions, ED visits, preventative care, and social activities. Provides trending and analysis to improve care and services.

• Researches and analyzes alternatives for improving programs and care. Develops “best practice” recommendations by partnering with outside organizations, examining data and identifying trends.

• Promotes healthy behaviors in all populations and provides navigation assistance with community resources. Organizes community educational events to increase awareness of preventative and wellness services.

• Participates in ACO and Medicaid care coordination meetings and training opportunities.

• Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Consistently demonstrates KVH values and provides all patients/customers with an excellent service experience.

• Performs other related duties as assigned.

Salary : $37 - $53