Chronic Care Coordinator

Primary Purpose

The person in this position is a member of the Patient Centered Health Care Home team and is responsible in planning, implementation and over-all care coordination and quality improvement activities for the patients with chronic disease. S/he participates in research and other projects that enhance patient care

• Supports the Patient Centered Health Care home team in planning, developing and implementing quality improvement activities related to chronic disease.
• Manages patients with chronic disease by creating and implementing a health care plan and self-management activities
• Conducts follow up either through face to face encounter, telephonically and/or in writing
• Teaches and/or coordinates classes for patients with chronic kidney disease
• Work in concert with other teams to achieve the goals and objectives or Patient Centered Health Care Home
• Assists in developing policies and procedures related to chronic disease
• Ensures that KPHC's chronic disease initiative and the patient centered health care home team asserts changes based on the components of the chronic care model & KPHC guidelines and plans for improvements are implemented.
• Provides monthly report and updates to the member of the team, senior management team and to the QI/QA committee.
• Collaborates with the Depression and the Health Care for the Homeless Diabetes Team in planning and implementing improvements.
• Serves as a liaison for chronic disease to other health centers and/or other organizations
• Explores community resources and establishes partnerships to facilitate improvements.
• Provides oversight for the maintenance of the health plans population management registry using i2i Tracks, Coseva, Guiding Care and other population management tools
• Supports other multi-cultural projects to enhance patient care.
• Coordinates short term projects as assigned
• Performs direct patient care and/or covers other departments as necessary.
• Administrative Responsibilities
• Assists the clinical operations coordinator in the coordination of day to day operations of the Patient Centered Health Care Home team
• Facilitates huddles and meeting as necessary
• Supports and supervises support staff working with him or her.
• Maintain an awareness of services offered through the clinic and in the community to serve client needs.
• Maintain awareness of legal and legislative issues that may impact service availability.
• Participates in clinic quality improvements activities.
• Work in concert with the patient centered health care home team to assess and modify quality improvement strategies.
• Maintains client confidentiality per clinic protocol.
• Develops and implements forms for data collection, tracking and documentation of activities and works with the adult medicine team to determine effective communication strategies.
• Work closely with other clinic staff engaged in activities or projects involving clients as it relates to chronic disease.
• Regular and reliable on-site attendance is required.

• Perform other related duties as assigned
• Observe safety and security procedures; determine appropriate actions beyond guidelines; report potentially unsafe conditions; use equipment and materials properly.

• Knowledge and skills in the delivery of community health nursing care
• Knowledge of Community Resources
• Ability to assess and plan in a multi-cultural context
• Ability to demonstrate cultural competency with multi-ethnic population
• Ability to work with a team
• Leadership Abilities
• Knowledge of MS office including Excel and Word.
• Knowledge of Practice Management software (Centricity, Dentrix, etc.) or Electronic Medical Records preferred.

• Licensed LPN in the State of Hawaii required
• Licensed RN in the State of Hawaii preferred

• 3 years general experience in the community providing community health education outreach preferred.
• Experience in medical office setting or Community Health Center
• Experience with multi-cultural population preferred
• The Chronic care Coordinator must command the confidence and cooperation of the various health team and the providers with whom s/he works with.

Kalihi-Palama Health Center is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.