Nurse Care Coordinator – Chronic Disease en High Country Community Health

Description

Department: Clinical Services

Immediate Supervisor Title: Clinical Director

Job Summary: The Nurse Care Coordinator - Chronic Disease position provides

assistance to the physicians and support staff by coordinating care and services for

patients in order to maximize use of available resources and to offer complete

preventative care to those in need. Working within the Registered Nurse scope of

practice, and in concert with the Primary Care Provider, patient, caregivers, family

members, other members of the Care Management Team and the community to

coordinate a full continuum of health care services considering the holistic needs of the

member, inclusive of unique social and cultural dynamics. This position will collaborate

with Care Managers while instructing individuals and families in the community about

health education and disease prevention utilizing a team-based approach. The Chronic

Disease Care Coordinator will work to provide medical case management services to

eligible patients within the Federally Qualified Health Center (FQHC). This nursing

position works to address the needs of the population served by assessing, planning,

implementing, coordinating, monitoring, and evaluating the options and services required

and using communication and available resources to promote quality, cost-effective

health outcomes. In addition, this position will support HCCH goals and objectives in

meeting performance improvement targets for various initiatives, data analysis that

supports care management, standardized plan of care expectations, and patient team

development and perform other duties as assigned to support the development of the

network.

Requirements

Job Responsibilities and Role on Care Team: This position will provide services to

patients within the organization by following applicable guidelines and best practice care

models. This position will function as an integral member of an interdisciplinary team

which will include the following: medical provider, behavioral health clinician, clinical

pharmacist, supportive services staff, and additional departmental staff.

This position description should not be interpreted as all-inclusive. It is intended to

identify the major responsibilities and requirements of this position. The incumbent may

be requested to perform job-related responsibilities and tasks other than those stated in

this description.