This position is eligible for an $8,000 sign-on bonus. POSITION OVERVIEW: To maintain the day-to-day operations and coordination of the Clinic Care Coordination Program for high-risk patients at Jefferson County Health Center. The Clinic Care Coordinator’s primary role is to assist outpatient departments with services provided to deal with medical, social, psychological, and emotional needs of patients providing continuum of care for patients throughout various health systems.

The Clinic Care Coordinator will also serve as a liaison between and among members of the healthcare team and providers to ensure optimal patient care. The Clinic Care Coordinator will collaborate with multiple disciplines, agencies, providers and community resources to access needed care. Will serve as a healthcare educator for patients and staff by utilizing their knowledge and providing, quality improvement and problem solving in the coordination of patient activities.

Graduate of an accredited school of nursing, with current Iowa RN or LPN license Minimum of 2 years of nursing care or social work experience ACCOUNTABILITY: Reports to Clinic Quality Supervisor DIRECT REPORTS: None POSITION-SPECIFIC

Care Coordination Identifies vulnerable inpatients that are high risk for readmission and coordinates outpatient services. Conducts face-to-face visits with patients in healthcare facility Assists with scheduling follow-up appointments, establishing a local provider, provider orders, set up appropriate local services per patient needs Act as liaison between patients, caregivers, support services, specialty providers and local providers Acts as a resource within the organization and the community regarding health issues Must have knowledge of healthcare practice, quality improvement concepts, patient/family education concepts and theories.

Also, must have knowledge of community resources and reimbursement mechanisms. Conduct face-to-face visits with patients Initiates telephone outreach and is available by phone during office hours. Work independently and keeps providers and/or nurses informed of patient status.

Provides health maintenance, and medication and disease management education to patients and families/caregivers. Collects, organizes, documents, and analyzes data, synthesizing it into understandable information Effectively communicates, problem-solves, and maintains productive and effective interpersonal relationships while effectively prioritizing. Must have exceptional customer service supporting patients and their families and provide compassionate care.

Connects patients with community and other resources. Assist patient with securing funding for medical care as needed. Accurately participates in medication reconciliation across continuum of care.

Ability to communicate with small and large groups. Attend ongoing training and courses to keep abreast of new developments in health care. Ability to maintain confidentiality; and both a high standard of courtesy and cooperation in dealing with co-workers, patients, and visitors, and satisfactory job performance despite the stress of a clinic work environment Attend meetings and in-services as required Coordinate, review and communicate appropriate laboratory tests and diagnostic studies Assists office staff as needed and perform other duties as assigned Transitional Care Weekly phone calls for 4 weeks as needed Collaborates with Case Manager-Discharge Planner Reinforce education and discharge instructions Chronic Care Coordinates outpatient services for vulnerable patients needing support to follow treatment plans and coordination of follow-up care.

Accepts and follows through with vulnerable patients referred to the program. Uses all components of Transitional Care Model and nursing process (within scope of practice) including assessment, planning, implementing and evaluating care to meet patients’ needs. Works with outside facilities and agencies on a routine basis, maintaining positive working relationships.

Coordinates continuity of care, prevention and avoidance of complications, and close clinical treatment and management under the direction of the patient’s primary healthcare provider(s) Check-in on the patient regularly and evaluate and document their progress. Clinic Wellness Assists with in-office patient care: Rooms patients in a professional and friendly manner Obtains vital signs Provide patient education, individualized information, counseling, support and advice Collect and document past medical and family history appropriately o Identify existing diagnoses for medical management and address any potential gaps in care Update problem list based on assessment data gathered Assess, recommend and document age-appropriate preventative screening services Refer patients to community programs when appropriate Provide, review and reinforce patient education regarding preventative care, disease entity, medications, dietary restrictions and other therapeutic regimens Review and/or establish immunization schedule and have ability to administer said immunizations Assess patient cognition and mobility Obtains consents when appropriate Works with other hospital departments to schedule tests and procedures o Communicates with pharmacies to order prescribed medications and refills as directed by the physician Returns calls from patients, pharmacies, other physicians, etc. in a timely manner Communicates with outside agencies as appropriate Accurately, completely and in a timely manner documents findings and outcomes of all above interactions in the electronic medical record and signs each entry Maintains a clean working environment: Cleans and keeps stocked exams/ procedure rooms Demonstrates appropriate instrument and safety procedures when cleaning and disinfecting per clinic routine Check medications and supplies for expiration monthly, properly disposing of expired medications and supplies Alerts manager to any problems with instruments, equipment or environment WORK ENVIRONMENT : Works in a well-illuminated, climate-controlled environment May come in contact with hazardous chemical or treatment modalities Possibility exists of exposure to communicable diseases Involvement in inpatient care may result in unavoidable work-related illness or injury Work environment is comfortable, with minimal exposure to physical hazards Moderate to loud noise environment when machines/equipment in use Involvement in checking in/moving of supplies may result in unavoidable work-related injury Must be constantly alert for patient/family emergency situations

Days shift · Monday
Thursday: 8:00 a.m.
5:00 p.m. | Friday: 8:00 a.m.
4:00 p.m. | 4-day work week optional