Care Coordinator

Job Summary
Assists all patients through the health system by acting as a patient advocate and navigator.

Qualifications
Bachelor's Degree in Nursing, Biology, Chemistry, Anatomy and Physiology, Public Health, Behavioral Science, or similar degree (Required)

Work Experience
2 - 3 years Clinical Setting (Required)
1 - 2 years Patient-Centered Medical Home clinical setting or knowledge of the Patient-Centered Medical Home initiative (Preferred)
2 - 3 years Experience in chronic disease management, case management, utilization management, and adult acute care (Preferred)
1 - 2 years Experience in Public Speaking (Preferred)
1 - 2 years Experience in Electronic Medical Records (Preferred)

Licenses and Certifications
Required Certifications/Licensures: Current License in the state of Georgia in occupant's area of specialty

Essential Functions
Assists all patients through the healthcare system by acting as a patient advocate and navigator. Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
Facilitates health and disease patient education, including leading group office visits.
Supports patient self-management of disease and behavior modification interventions.
Coordinates continuity of patient care with external healthcare organizations and facilities, including the process hospital admission and discharge and referrals from the primary care provider to a specialty care provider. 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, including a registry.
Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed. Facilitates patient medication management based upon standing orders and protocols.
Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home and Medical Neighborhood initiatives.

Additional Duties
Adheres to the hospital and departmental attendance and punctuality guidelines.
Performs all job responsibilities in alignment with the core values, mission and vision of the organization.
Performs other duties as required and completes all job functions as per departmental policies and procedures.
Maintains current Knowledge in present areas of responsibility to include any specialty certification requirements (i.e., self-education, attends ongoing educational programs).
Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
Demonstrates competency at all levels in providing care to all patients based on age, sex, weight, and demonstrated needs. For non-clinical areas, has attended training and demonstrates usage of age- specific customer service skills.
Wears protective clothing and equipment as appropriate.