NURSE CARE COORDINATOR
Company: Comprehensive Community Health Centers Inc.
Posted on: May 14, 2022
JOB SUMMARY The Care Coordinator supports the CCHC Care Model by
working with patients, families, providers, and staff. The Care
Coordinator promotes/assists with timely access to needed care,
provides daily continuity of care coordination and instructs
patients, families and caregivers in an effort to help them
understand the patient's care plan and self-care management
responsibilities. The Care Coordinator is an essential member of
the patient care team, who helps empower patients and families to
take ownership and to have an active role in their healthcare.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Participate in daily care team huddles.
- Treat patients with empathy and respect and conduct oneself in
a professional manner.
- Identify and monitor all patients based on risk and outcomes
and actively identify patients for involvement in care coordination
- Engage patients, patients' families, and their caregivers in
understanding, setting, and monitoring patient self-management care
plans in a manner that is culturally and linguistically appropriate
to the patient and caregiver.
- Consult with patients, their family members and/or chosen
support system to identify barriers and to set goals in
correspondence with their health needs.
- Comply with organizational guidelines and health laws and
- Provide health education to patients about their health
condition/s and related topics.
- Complete health risk assessments as a foundation for developing
individualized care plans and outcomes goals for patients and their
- Document each patient's individualized care plan and care
coordination in the Health Center's database.
- Conduct follow-up calls/check-ins with the patient to determine
progress with patient set goals
- Coordinate the patient's care by facilitating patient, family,
or other caregiver access to medical providers, staff, and
resources as needed by the patient.
- Conduct and document assessments of patient needs and resources
for effective self-care management.
- Develop and maintain relationships among patients, patients'
families and the patients care team that support patients access to
the medical home.
- Apply the principles of comprehensive, community-based care, to
provide developmentally, culturally and linguistically appropriate
- Use case coordination processes to assure quality care is
delivered to the Health Center patients, the patients' families,
and the patients' caregivers in the most efficient and effective
manner across the healthcare continuum.
- Research, find and link patients to resources, services and
support mechanisms for their care plans and self-care management's
- Provide timely communication with patients, make inquiries,
execute follow-up actions, and help to integrate information into
the care plan.
- Assist the care team by helping to measure quality and
identify, refine, and implement performance improvements that
support the medical home.
- Assist the care team in performance evaluation and quality
- Continuallymonitor the cost effectiveness of services provided
through the patient's individualized care plans, and recommend any
needed changes to those plans based on evidence based clinical
guidelines from sources identified by the Practice.
- Participate in continuing professional growth through
attendance of workshops and professional in-services and through
individual research and reading, to include communication
- Participate in population management activities as directed by
the Health Center.
- Attend and participate in organized functions of the Health
Center and perform administrative function as necessary.
- Demonstrate personal responsibility and respect for patients,
patients' families, and co-workers in professional appearance.
- Assist with teaching families and personnel.
- Perform duties in a manner that is culturally and, if
applicable, linguistically appropriate.
- Demonstrate flexibility, enthusiasm, and willingness to
cooperate while working with others in multi-disciplinary teams
with activities to include participating in daily huddles.
- Transitions of care (which may include from Pediatrics to
- Performs other related duties as assigned. .
EDUCATION, TRAINING AND EXPERIENCE
- Graduated from an accredited school of professional nursing or
from a national or state approved school of vocational
- Licensed as a vocational nurse in California (LVN) with
clinical experience of at least 3 years or a Bachelor's of Science
Degree from a 4-year college or university.
- Health Coach certification and/or motivational interviewing
- Demonstrated skills in leadership, advocacy, communication
education and counseling
- Culturally effective capabilities demonstrating a sensitivity
and responsiveness to varying cultural characteristics and
- Bilingual (defined based on the linguistic and cultural needs
of the patient population) KNOWLEDGE, SKILLS AND ABILITIES
- Ability to find solutions when barriers are identified.
- Strong documentation skills.
- Ability to multi-task and prioritize when needed.
- Ability to independently seek out resources and work
- Ability to read, understand and follow oral and written
- Experience and work ethics that supports working within a high
functioning, team-oriented environment.
- Demonstrates a willingness and ability to work under
- Ability to develop and maintain good working relationships with
- Ability to use computer and learn new software programs.
- Excellent interpersonal skills reflecting clarity and diplomacy
and the ability to communicate accurately and effectively with all
levels of staff and management.
- Demonstrates ability to work in a regulatory climate that
includes oversight of state and federal entities, payer contracts
- Possesses ability to communicate effectively, both verbally and
- Possesses genuine respect for others and acceptance of their
individual social and cultural traits.
- Proficient knowledge of Microsoft Outlook.
- Able to travel and attend professional meetings, conferences,
trainings and clinic sites.
- Demonstrate flexibility, enthusiasm, and willingness to
cooperate while working with others in multi-disciplinary
- Performs other related duties as assigned. PHYSICAL DEMANDS
Position requires prolonged sitting at a computer, some bending,
lifting, stooping and stretching. Good eye-hand coordination and
manual dexterity sufficient to operate a computer keyboard,
photocopy machine, telephone, and other office equipment is also
required. Employee must have normal range of hearing and eyesight.
NOTE: The essential job functions for this position include, but
may not be limited to those listed in this job description.
Employees hired for this position must be able to perform the
essential functions of this job without imposing significant risk
of substantial harm to the health or safety of themselves or others
Keywords: Comprehensive Community Health Centers Inc., Glendale , NURSE CARE COORDINATOR, Healthcare , Glendale, Arizona
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