The Embedded Ambulatory Care Coordinator is responsible for communication and coordination of care in collaboration with SIHO/MTA Membership, their care providers and additional SIHO team members to reduce care gaps, optimally use care resources, and increase quality of care delivery.
Under the supervision of the SIHO Manager of Care Management, the Embedded Ambulatory Care Coordinator (EACC) provides oversight of patient populations at the physician practice level. The EACC is responsible for assisting to close gaps in care, aid in coordination of care, and assist in the improvement of quality care delivery for the SIHO/MTA membership. This position works in collaboration with the health system clinical teams and leadership to support patient/family needs and to create quality and effective plans of care.
Brief Description of Duties:
- Perform timely coordination of quality healthcare services to meet an individuals specific healthcare needs in a cost-effective manner to promote positive outcomes.
- Develop solutions to achieve cost efficient resource utilization, preventing readmissions and unnecessary emergency room visits.
- Work collaboratively with Physicians, nursing, other members of the disciplinary team, home health agencies and Skilled Nursing Facilities as well as other resources external to the organization.
- Communicate with internal and external customers and care providers in a positive and professional manner to promote patient/provider satisfaction, quality of care delivery and an increased awareness of appropriate utilization.
- Assist the SIHO Manager of Care Management and health system clinical teams with a variety of initiatives and projects supporting the initiative of closing gaps in care.
- Make appointments for patients who are overdue for labs, tests or procedures.
- Coordinate efforts with physician practice staff to be proactive in addressing Best Practices with each patient to maximize patient satisfaction and adherence
- Communicates with SIHO Manager any issues or concerns in completion of required job duties
- Monitor EMR for patient compliance with routine preventative and disease management care
- Coach patients/families toward successful self-management of their chronic disease.
- Communicate with hospital system clinical team to assist in addressing unmet health and social needs identified
- Provide effective communication to improve health literacy.
- Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator).
- Cultivate and support primary care and specialty co-management with timely communication, inquiry, follow up, and integration of information into the care plan
- Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
- Associates of Science in Nursing (ASN) required
- Bachelors of Science in Nursing (BSN) preferred
- 5 years of clinical experience
- Current Indiana RN License required
- Basic Life Support (BLS) certification through American Heart Association (AHA) required.
Other Skills and Abilities
- Maintain current knowledge of health care practices related to clinical practice and/or the nursing process.
- Ability to work with client families with diverse opinions and diverse religious and cultural ideals and values.
- Ability to work autonomously with minimal direction and directly accountable for practice.
- Demonstrates a wide-theory base and sound clinical skills.
- Critical thinking skills and ability to analyze complex data sets required.
- Ability to prioritize work independently and respond to multiple simultaneous requests
- Ability to recognize needs and behaviors of specific age groups of assigned patients
- Utilization of critical thinking in timely decision making
- Embrace a changing paradigm in innovative care management and the need to foster robust, coordinated, and integrated care across the continuum of care
- Possess leadership qualities including: time management, verbal and written communication skills listening skills, problem solving, decision-making, priority setting, work delegation, interpersonal communication and work organization
- Computer skills including Microsoft Outlook, Excel and Word