Benefits: Medical, Dental and Vision. Worksite Wellness Program, EAP, 457 retirement fund, 403B retirement plan with 3% matching after 1 year of employment, 160 PTO hours within the first year and so much more.
“To provide high quality, integrated primary, behavioral, and dental health care in the communities we serve, with special consideration for the medically undeserved, regardless of ability to pay.”
We are a strong and rapidly growing Community Health Center located in the beautiful Colorado Mountains, with strong schools, abundant outdoor activities, and vibrant communities. We provide integrated medical-dental-behavioral health care, with 9 service delivery sites, 21,000 patients served, $19M annual operating budget, and 200 staff. We are recognized as a Level 3 Patient Centered Medical Home by the National Committee on Quality Assurance.
Here, you get to grow as a professional and develop the skills pertinent to meeting the needs of employees and patients. You will work with an experienced leadership team with multiple state and national awards for healthcare innovation. But most important, YOUR career will be about making a difference while living in paradise.
Under the direction of the Integrated Care Director, utilize the nursing process for provision of care coordination services to patients who are most at risk for health deterioration, Social Determinates of Health, sentinel events and/or poor outcomes; ensure the PCP (primary care provider) team maintains a central role in coordinating and managing the care of vulnerable patients and that patients receive comprehensive care across multiple health settings and providers; utilize the nursing process to ensure continuity and coordination of care across transitions of care for all patients, with attention to patients with complex medical and social needs; support patients and care teams in chronic disease, care management. Support pursuit of facility Quadruple Aim of improved patient outcomes, enhanced population health, staff satisfaction and controlling cost.
Care Coordination Duties:
1. Integration of the patient/family into care coordination and care management planning and communications, assuring that the patient/family are informed and supported in decision-making.
2. Transition care for patients discharged from the hospital within 24 – 48 hours to prevent readmission and related complications. Provide medication reconciliation, triage, follow-up appointments, and education.
3. Evaluation of and appropriate follow-up care for patients seen in the emergency department to prevent further disease exacerbation, untoward complications, or additional ER or hospital utilization.
4. Evaluation of the ACC, RCCO, PRIME, ACO and patient list to determine patients at highest risk for health deterioration, social determinates of health, sentinel events, and/or poor outcomes.
5. Maintenance of a care management registry for documentation of highest risk patients, care management interventions, and care plans.
6. Timely and ongoing communication with the PCP, behavior health, practice teams and others to identify highest risk patients and to maximize the management of patient needs and related risk reduction.
7. Coordination of care with other care managers (home health care, payer case managers, etc.) and with specialists to maximize health and social and health care, and promote patient safety.
8. Support tracking and documentation systems for patients admitted to and discharged from the hospital(s), patients seen in the emergency room (ER), and patients transitioning from or to any other health care facility.
9. Assure that care is patient-centered and that the patient/family are informed about the plan of care and are involved in decision-making about that care.
10. Comprehensively assessing patient’s physical, behavioral, and psycho-social needs.
11. Assist PCP in developing care plans that prevent disease exacerbation, improve outcomes, increase patient engagement in self-care, decrease risk status, and minimize hospital and ER utilization.
12. Utilize behavioral strategies to assist patients in adopting healthy behaviors, improving self-care, improving social support/services and managing chronic disease.
13. Assist patients in problem-solving issues related to the health care system, financial and psycho-social barriers.
14. Communicate patient needs, plan of care, and changes in status with the PCP, team and the patient/family.
15. Develops and supports effective partnerships within the community to better meet patient needs.
16. Participates in innovative pilots and directives set forth from facility.
1. Demonstrates assessment and identification of patient/family health and social needs.
2. Work with behavior health to coordinate behavior health services to patients.
3. Assists with assessing the patient to facilitate care planning and identification of problems.
4. Utilizes data collected and reported by providers, other clinical support staff, payers, patients/families/significant others, other disciplines and community agencies.
5. Demonstrates the ability to teach and assess patient learning, including informational handouts.
6. Provides clear and concise patient education and instruction in understandable terms.
7. Documents relevant information in the EHR according to facility and nursing requirements.
8. Supports client groups set forth from program funded projects.
Education or Formal Training & Experience:
a. Registered Nurse with two (2) years’ experience in primary outpatient care preferred
b. Current Colorado license
c. Current B.L.S. certification