Clinical Care Coord​/RN - Anticoagulation Clinic

Clinical Care Coord/RN - Anticoagulation Clinic - 89980

Northern Light Mercy Hospital | US:

ME:

Portland or Hybrid | Nursing-RN | Full Time

Northern Light Mercy Hospital

Position is located: Mercy Medical Office Building

Work Type: Full Time

Work Schedule: Variable

Summary:

The Clinical Care Coordinator designs, implements and participates in care coordination practices that seek to improve patient outcomes and decrease costs while consistently demonstrating effective patient-centered care. The incumbent coordinates and guides the patient navigation process for patients and their families with a cardiac diagnosis or other complex surgical/medical events. The Clinical Care Coordinator collaborates with an interdisciplinary team to ensure high quality care across all delivery sites and serves as a single point of contact for patients, caregivers, referring physicians and the community.

The Clinical Care Coordinator works closely with physicians to develop data processes/analysis in order to track patient progress and outcomes. The Coordinator will be responsible for updating and maintaining American College of Cardiology databases, and is responsible for participation in and compliance with all patient safety initiatives and regulations associated to the position. Conducts all job responsibilities according to the Mission and Values of the Hospital.

Is fully compliant with HIPAA regulations.

Responsibilities:

• Collaborates with physicians and ancillary staff, other services, patients and patient’s family to create patient-centered care coordination, manage symptoms, and evaluate patient outcomes.
• Meets with patients and patients’ family with a new diagnosis of cardiovascular disease or other complex surgical/medical diagnosis to provide anticipatory guidance, education, psychosocial support, answer questions, and facilities appointment scheduling and access to resources during the treatment-planning phase.
• Serves as a single point of contact for patient’s, patient’s family, referring physicians and other members of the integrated, multidisciplinary healthcare team who have questions about the plan of care, need guidance with care coordination and access of additional clinical and/or supportive resources, or questions related to pre and post care.
• Responsible for the coordination and delivery of clinical nursing care and services according to current policy and standards of care.
• Initiates patient education and follow-up according to the individualized treatment plan, physical and psychosocial needs of the patient in collaboration with the physician.
• Collaborates with the clinical and multidisciplinary team to support the navigation process regarding the care of highly complex patients to assure continuity during care path transitions.
• Make appropriate referrals to social services, financial counselors, nutrition, home care, and additional community services to support a comprehensive quality care model.
• Provides consistent care coordination to patients and families through assessment of actual or potential health needs, health promotion, education, symptom management, counseling and decision support and coordination of care across all care sites.
• In collaboration with physician and interdisciplinary care team, coordinates a follow-up plan of care after the initial phase of a patients treatment is complete
• Serves as a liaison to the in-patient unit and home care agencies in the communication and coordination of continuous patient care.
• Conduct follow-up patient calls post hospital discharge and/or following changes in the patient plan of care to evaluate nutritional needs, education needs, level of understanding, outcomes and reinforce the plan of care.
• Assists in the coordination, scheduling and tracking of patient compliance with appointments, screening, diagnostic and follow-up tests and procedures.
• Tracks, reviews and monitors follow-up of diagnostic test results, under the direction of the physician. Provides related education, counseling, ongoing review and monitoring regarding diagnostic tests.

Other Information:

BLS Required.

Competencies and Skills

• Behaves…