Nursing Care Coordinator

HealthWorks for Northern Virginia is a non-profit Federally Qualified Health Center (FQHC) serving the medically underserved and uninsured populations of Northern Virginia. We provide quality medical, dental, and behavioral health care to all ages who might not otherwise be able to afford it. For more information about who we are and what we do, please visit www.hwnova.org.

Work Life Balance ? NO WEEKENDS!! Competitive Salary and Benefits package includes a 401K Retirement Plan, Medical, Dental, Vision, Group Life, STD, LTD; Paid Time Off and 10 Paid Holidays.

HealthWorks is a mandatory COVID-19 and flu vaccine organization.

Pay range $55k - $60k

Description of Duties:

As a member of the health care team, working under the supervision of the Director of Nursing. The duties of the Nurse Care Coordinator include:

Position Role and Responsibilities:

• Adhere to all Healthworks of Northern Virginia policies and procedures.
• Assists all patients through the healthcare system by acting as a patient advocate and navigator.
• Creating an evidence-based care plan for providers and an action plan for patients and caregivers.
• Identify the patient?s and family?s physical, psychosocial, environmental, safety and developmental needs and individualizing the patient?s plan of care based on the needs identified.
• Promoting patient self-management and disease and behavior modification interventions.
• Coordinates continuity of patient care with patients and families following hospital admission, discharge, and ER visits.
• Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Coordinating the efforts of all care providers (hospitals, specialists, rehab facilities, home care, hospice, and social service agencies).
• Smoothing transitions between sites of care, (e.g., transitions into and out of hospitals).
• Educating and supporting family caregivers.
• Facilitating access to community resources.
• Document problems, nursing assessments, appropriate goals, care provided, care interventions and patient and family outcomes achieved from intervention and care provided.
• Teach appropriate interventions, medications, effects and side effects to patient, caregiver, volunteers and others as appropriate.
• Participates on a team for data collection, health outcomes reporting, clinical audits, and evaluation related to Patient-Centered Medical Home.