Clinical Care Coordinator

Position Summary

Under general supervision of the Patient Centered Medical Home (PCMH) Manager, the Clinical Care Coordinator will independently work in conjunction with multidisciplinary team members involved in the care of patients at the Winslow Indian Health Care Center (WIHCC). The role is responsible for delivering timely, appropriate, and beneficial care by promoting quality and cost‑effective health care outcomes in a seamless continuum of care.

The coordinator works within established standards for clinical care coordination, case management principles, and advance access principles while upholding WIHCC’s Vision, Mission, and Values. Confidentiality of all privileged information is maintained at all times.

• Maintain regular attendance and punctuality.
• Perform chart reviews for upcoming appointments of patients on the panel.
• Track outstanding tests and results, including monitoring consult results for upcoming appointments.
• Conduct post‑discharge phone calls as follow‑up for identified high‑risk patients in their panels.
• Assist in coordinating care between hospitals and develop a continuous tracking database for active management of assigned patients.
• Collaborate proactively with all interdisciplinary team members to facilitate and maximize patient healthcare outcomes.
• Coordinate multi‑disciplinary patient care conferences for high‑risk or complex patients as needed.
• Maintain compliance with applicable laws, including patient confidentiality, abuse reporting, consent principles, and advanced medical directives.
• Advocate for the customer/family at both the service‑delivery and policy‑making levels, fostering independence and decision‑making.
• Utilize best practice models to identify, incorporate, or develop best practices for panel management.
• Collaborate with others to share and establish best practice for clinic and division operations.
• Act as the resource nurse in the clinic, coordinating with other service lines as needed.
• Manage panel acute and chronic care needs, meeting or exceeding clinic expectations for health maintenance standards (GPRA).
• Integrate factors related to quality, safety, efficiency, and cost effectiveness into planning, delivering, monitoring, and evaluating customer care.
• Use campus software packages and applications for ordering, scheduling, and tracking customer care.
• Assist in tracking referrals and results prior to appointments in coordination with WIHCC providers, specialists, and close collaboration with Inpatient and Outpatient RN Case Managers in CHS.
• Initiate needed therapeutic measures and general nursing care.
• Participate in department, WIHCC teams, and committees.
• Engage in the ongoing development of case management and care coordination within the primary care – advanced access model.
• Coach and mentor all clinical team members to build or enhance capability and competency.
• Assist in the implementation of nursing systems that support the mission of the American Academy of Ambulatory Care Nursing (AAACN).
• Make meaningful improvements to services, programs, and processes to create new value for customers and employees.
• Complete tasks or duties assigned by a supervisor.
• Uphold all principles of confidentiality and patient care to the fullest extent.
• Adhere to professional and ethical behavior standards of the healthcare industry.
• Follow WIHCC Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Interact honestly, trust worthily, and dependably with patients, employees, visitors, and vendors.
• Possess cultural awareness and sensitivity.
• Maintain compliance with all Human Resources requirements.
• Perform other duties as assigned.

• Knowledge of standard nursing care for patients across all ages.
• Knowledge of the scope of patient care services provided by other clinical service lines and the referral process.
• Knowledge of effective teaching processes and principles for health care planning and evaluation.
• Knowledge of quality management and improvement processes to comply with internal and external accreditation standards.
• Knowledge of general medical procedures and the ability to anticipate…