Clinical Coordinator - Collaborative Care Model (Grant Funded)

We are currently seeking a Clinical Coordinator to join our Collaborative Care Model (CoCM) team in the Adult Medication for Opioid Use Disorder Clinic. This full-time role will primarily be day shift with on-site work  at the Minneapolis downtown hospital/cliniccampus. This is a grant funded position through a five-year grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), in collaboration with the Minnesota Department of Human Services. 

SUMMARY: 

The Clinical Coordinator is responsible for facilitating and coordinating the care delivered to  patients with opioid use disorder and mental illness through multidisciplinary and patient/family collaboration to ensure high quality care and improved health outcomes. Coordination involves assessment, planning, support, and evaluation of patient care and related outcomes. Activities to be performed are patient/family interviews, clinical resource management, utilization management, conduct of medication protocols, and coordination of transition planning/care continuity 

The Clinical Coordinator is an active contributor in the development of systems to improve the care coordination of patients with opioid use disorder and mental illness enrolled in the Collaborative Care model. This role encompasses coordination across multiple team members for  utilization management,  transitions of care planning, and care continuity for patients in the Adult Medication for Opioid Use Disorder Clinic.   

Clinical coordinators establish individualized systems of care to a ensure seamless transition to the right services and right providers at the right time and encourages patients and families to take an active role in managing their own health.   

RESPONSIBILITIES:

• Provides Care Coordination for patients, physicians and care providers
  • Plan, implement and evaluate transition functions and activities for a caseload of patients across the continuum care
  • Contribute to the development and implementation of individualized patient care plans that meet patient population goals/standards
  • Ensure implementation of the treatment plan for achievement of clinical outcomes consistent with the needs and preferences of the patient and family
  • Communicate with patients families and the health care team to ensure seamless transitions between levels of care
  • Enable efficient movement of patients through the care process by reducing delays and ensuring appropriate resource utilization. Involve patients and families in the discharge, transition processes
• Provide services to streamline plans of care, reduce hospital readmissions, ease the transition to long term services and supports, and interrupt patterns of frequent hospital emergency department use
• Facilitate implementation of best practice standards
• Maintain plan of care across continuum of care
• Responsible for a caseload of patients
• Incorporate utilization review activates concurrently across the continuum of care
• Actively track outcomes and participate in quality activities specific to patient population/departments served
• Provide information/education to healthcare providers to support changes for care delivery to patients and patient populations that meet quality, cost, and service goals
• Delegate tasks as appropriate to other members of the health care team
• Promote effective working relations and works effectively as part of a department/unit team inter and intra-departmentally to facilitate the department's/unit's ability to meet its goals and objectives
• Identify and address potential legal and ethical issues around care management/care coordination
• Demonstrate understanding of reimbursement mechanisms and the impact of length of stay on quality, financial and satisfaction outcomes
• Coordinate with payer case management to ensure coordinator effective approach to help patient meet goals 
• Help to evaluate effectiveness of interventions related to cost and length of stay goals
• Demonstrate respect and regard for the dignity of all patients, families, visitors and fellow employees to ensure a professional, responsible and courteous environment
• Demonstrate understanding of diversity issues related to patient care
• Understand and meet the requirements of the Corporate Compliance Program; complies with the standards set by department policy, The Joint Commission and other regulatory agencies governing activities within the department 100% of the time
• Understand and meet the requirements for health care home certification
• Make field visits to patients homes

RESPONSIBILITIES - Collaborative Care Model (CoCM)

• Actively performing patient outreach and engagement to  support patients' individualized care plans and access to care/continuity of care in their recovery journey 
• Performing patient-centered intake assessments and substance use history 
• Educating patients on disease/substance use disorder(s) and other co-occurring mental and physical health conditions 
• Refilling medication for opioid use disorder based on clinic protocol and administering injectable medications in clinic as ordered by a medical provider  
• Collaborating with HHS addiction medicine clinic and community partners to support patients' recovery needs 
• Working closely with primary care providers and psychiatric consultants to ensure all aspects of the CoCM  are being appropriately utilized for clinic patients 
• Working on the level of clinic population health for appropriate panel management and CoCM caseload at any given time 

Minimum Qualifications:

• Bachelors degree: BSN, BAN
• At least 2 years of experience working directly with patients experiencing substance use disorder and mental health conditions such as depression and/or anxiety disorders
• Experience with buprenorphine and methadone and following protocols to refill these medications 
• Experience in the outpatient setting engaging high risk populations in follow-up and individualized plans of care and harm reduction 

HCMC employees who became Clinical Coordinators (Sr. Staff Nurses) prior to August 13, 2012 and do not possess a Bachelor's degree in Nursing are considered qualified.

• Must have worked as a professional nurse for the past three to five years 
• Must have experience in acute care and/ or ambulatory care 
• Must have demonstrated professional leadership (i.e., charge, team leader, preceptor, committee chair, etc.) 
• Current Minnesota RN licensure

Preferred Qualifications:

• Case management certification preferred but not required