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SalaryThis position is responsible for the management of the Coordination of Care and Transition Management Department and for providing Clinical Care Coordination and transition of care for the patients of Spirit Lake Health Center. Coordination of Care and Transition Management is a process of patient assessment, integration of services, and follow-up and evaluations enhance the continuity of patient care. The Clinical Care Coordination Supervisor will interact and collaborate with members of the multidisciplinary health care team on an ongoing basis and participate in the clinical decision making process. They will consistently promote and provide safe and appropriate nursing care within the framework of the mission and vision of the Spirit Lake Health Center and in collaboration with other members of the health care team. The individual will also contribute to the environment of care through maintenance of safe and supportive environment for patient, staff and other individuals served by or providing services in the organization. Work is performed and duties are carried out in accordance with established policies, procedures, and SLHC core values. Responsible for adhering to Ambulatory Care Policies and Standards of Nursing Care.
Major Duties & Essential Functions:
The following list of duties is not intended to be restrictive or all inclusive. The fact that certain duties may not be listed does not limit the assignment of additional and/or other duties.
• Provides leadership and management oversight of all the daily activities of the Coordination of Care and Transition Management Department related to budget, purchasing, personnel, administration and performance management, ensuring safe and efficient patient care.
• Hires, trains/precepts, assigns, schedules, directs, supervises, evaluates and disciplines assigned personnel.
• Assess day-to-day workload requirements and makes staff assignments according to appropriate skill level.
• Monitors Clinical Care Coordination and transition management flow to ensure safe, high quality care and maximum utilization of staff and other resources.
• Identifies and orders equipment and supplies necessary for safe and necessary functioning of the department.
• Recommends establishment or revision of policies, procedures, and methods and develops organizational structure and standards of performance.
• Consults with Chief Executive Officer, Medical Director, Director of Nursing, Department Heads and others to coordinate department activities.
• Coordinates and maintains patient referral system to provide adequate and appropriate information for effective follow-up.
• Assists with the development, revision, and coordination of the Plan of Care through collaboration with the multidisciplinary treatment team to meet the patients’ needs effectively and efficiently
• Develops short term and long term strategies in the development of expected patient outcomes; collects data through patient tracking in order to measure outcomes
• Works collaboratively with provider(s) and other staff to ensure the delivery of quality care to patients and best patient outcome. Provides guidance and assistance with the orientation of the medical support staff.
• Works with providers, staff, other Tribal Programs, outside vendors, third party payers, families, community resources, etc. to facilitate care of the patient throughout the continuum of care
• Coordinates appointments and procedures for patients who need further care or continuity of care at other facilities.
• Coordinates with allied medical services or outside vendors as needed to obtain equipment and needed supplies for patients.
• Assists with arranging appointments for patients at Spirit Lake Health Center and outside providers.
• Obtains result of labs, test and scans done at outside facilities and reports them back to referring provider and/or PCP. Obtains discharge summaries from hospital/ED visits, and other medical records from other health care facilities regarding referrals and confirmed appointments.
• Assists with appropriate and timely information transmission to and from specialists.
• Works closely with the PRC department to optimize and improve the Referral Process for the patients at SLHC.
• Assesses, plans, implements, coordinates, and evaluates the effectiveness of the patient programs. Follows up with patients that have not followed through on their plan of care patients via phone, mail, and/or Public Health Nursing consults. Works with local and surrounding transportation teams that facilitate/assist with transportation for patients medical appointments.
• Serves as a resource contact and information/education source to patients, families, providers, and/or staff
• Assists in the development, revision, and implementation of patient programs and/or marketing programs, materials, and resources in specialty area to meet the specific needs of the patient population
• Defines and directs patients and/or families to appropriate resource utilization
• Collects data through patient tracking in order to facilitate patient outcome data collection and analysis
• Develops and maintains an effective quality assurance (QA) opportunities using patient data/clinical outcomes and conducts evidence based improvements
• Promotes patient and staff safety.
• Maintains a clean, safe, orderly and therapeutic working environment.
• Identifies system/organizational processes which may affect effective utilization of resources, timely scheduling of tests, appropriate level of care being given, etc., and collaborates with team members to improve upon the processes
• Identifies practice and/or program improvement opportunities to assist with securing the highest level of payment/reimbursement
• Maintains knowledge and satisfactorily complies with regulatory and third party payers’ procedures, notification requirements and criteria, documentation required in the medical record, etc.
• Attends in-services and staff meetings as scheduled
Knowledge required at a level appropriate for this position:
• Knowledge of HIPAA.
• Knowledge of a full range of professional nursing principles, practices, and established concepts, principles, and procedures required to provide care to ambulatory patients of moderate difficulty with a wide variety of conditions which also involves consideration of the physical and psycho/social-cultural aspects. Ability to communicate clearly and effectively, both orally and in writing, using tact and sensitivity.
• Ability to maintain professional conduct in all work‐related and/or emergent situations
• Ability to efficiently and effectively manage multiple tasks
• Ability to work in a fast paced, patient service oriented environment
• Skill in prioritizing and organizing work, and maintenance of files and records.
• Skill in the provision of customer services.
• Skill in the use of such office equipment as a computer, scanner, fax machine, and copier.
• Knowledge of customer service principles.
• Knowledge of SLHC Nursing Department policies and procedures
• Knowledge of the correct and effective use of English, including grammar, spelling, and punctuation.
• Knowledge of modern office practices and procedures.
• Demonstrates good organizational skills in the preparation of daily work schedules and the assignment of duties and responsibilities
• Ability to work with personal computer and utilize a variety of software applications, including database and office software systems. (iCare, EHR, RPMS and Microsoft applications)
• Possesses outstanding interpersonal skills, including excellent written and verbal skills
• Performance improvement or patient safety knowledge required
• Demonstrates ability to promote quality improvement through development and maintenance of standards
• Thinks critically; utilizes sound judgment; promptly reports potential patient safety risks to provider and/or manager
• Ability to effectively work with and through physicians, subordinates, customers, and other personnel in a cooperative, collaborative manner in order to improve clinical quality outcomes
Supervisory Controls:
The employee reports directly to the Clinical Director, who provides guidance and assists with unusual problems. The employee exercises initiative, judgment and problem-solving techniques related directly to the overall Care Coordination and transition management of the patients at SLHC. The employee functions independently in planning day to day management of the coordination of care and transition management program. Over sees and provides guidance to the staff members of the department. Work is reviewed through conferences, reports and observation of operations of the Clinical Care Coordination and Transition of Care Department. Guidelines: Guidelines include SLHC policies, standards of care, and doctor’s orders, clinical and administrative plans and objectives of SLHC, and AAAHC standards. Judgement is required to assess the patient’s needs and to make appropriate decisions in regards to the coordination of care and transition management. These guidelines are generally clear and specific, and deviations must be authorized by the supervisor.
Complexity/Scope of Work:
This position consists of clinical and varied administrative, managerial and supervisory duties. The varied scope of responsibility and the community’s vast health care needs contributes to the complexity of the work. The purpose of this position is to deliver patient Care Coordination and transition of care services to SLHC patients. Successful performance helps ensure improved patient outcomes. The work affects the health and recovery of patients and well-being of family units; in addition to a range of activities and how the coordination of care and transition management program is perceived by the community.
Contacts:
Contacts are with patients and their families, professional and non-professional health care personnel at SLHC. Addition contacts are with other healthcare personnel, and non-professionals, employees at other facilities and in the general community. The purpose of the contact is to facilitate healthcare delivery to patients and requires effective interpersonal skills in dealing with patients, their families and providers. Contact are with hospital and community programs to exchange, provide and obtain information. Contact with patients and their families are to counsel, teach, influence and motivate patients to develop and maintain good health habits. Contact with outside agencies for the coordination of health care and other patient services.
Physical demands/Work Environment:
The work is typically performed standing or sitting. The work is typically performed in an office setting, and occasionally in a clinic setting which requires normal safety precaution for infection control and environmental safety measures. The work environment is usually moderate. While performing the duties of this job, the employee is regularly required to stand and sit, talk, and hear. The employee is frequently required to reach with hands and arms. The employee is occasionally required to walk and stoop, kneel, or crouch. The employee must regularly lift and/or move light objects, and occasional lift heavier objects. Specific vision abilities required by this job include close vision, color vision, and ability to adjust focus.
Supervisory and Management Responsibility:
Manages the employees within SLHC Coordination of Care and Transition Management Department. Is responsible for the overall direction, coordination, and evaluation of the department. Carries out supervisory responsibility in accordance with applicable personnel system policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
Qualifications, Experience and education required:
• Bachelor’s Degree in Nursing, an Associate’s Degree or a Diploma of Nursing and experience sufficient to understand the major duties of this position and maintains an active unrestricted license as a Registered Nurse
• Must successfully pass a criminal and background check and a pre-employment drug screen.
• Current BLS, ACLS, and PALS certification.
