Summary: Coordinates team- based care within the Accountable Care Organization (ACO) including hospital, physician, and other providers, and monitors Plan of Care to provide exceptional and efficient patient care to individuals through effective partnerships with patients, their caregivers, and their physician(s) and/or provider. Facilitates a shared goal model within and across settings to achieve coordinated high-quality care that is patient/family centered.

Job Responsibilities:

• Provide a coordinated strategic approach to detect early and manage effectively the patient with chronic disease. Establish an effective internal tracking system for identified patients.
• Coach patients/families toward successful self-management of their chronic diseases.
• Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care:

• Assess patient and family’s unmet health and social needs.
• Provide effective communications to improve health literacy
• Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
• Create ongoing processes for patients/families to determine and request the level of care coordination support they desire at any given point in time.

• Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
• Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (i.e. Dietician, Diabetes Educator, etc.)
• Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions in care and referrals.
• Serve as the contact point, advocate, and informational resource for patient, family, care team, payers, and community resources.
• Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
• Develop systems to prevent errors (i.e. effective medication reconciliation and shared medical records).
• Facilitate and attend meetings between patient, families, care team, payers, and community resources as needed.
• Attend all Care Coordination related training and meeting activities through Illinois Critical Access Hospital Network (ICAHN)
• Provide feedback for the improvement of the Care Coordination Program.
• Ensure compliance of Quality Metrics through data abstraction on an ongoing basis.
• Provides written report of Quality Metric compliance on a monthly basis to CNO and Providers. Monitors for trends and makes improvements with assistance of Providers as needed.
• Assists in data abstraction and submission to ICAHN as requested.
• Provide the Annual Medicare Well Visits to Medicare patients if needed.
• Emphasize continuity of care, thus reducing or eliminating fragmentation, duplication, and gaps in Treatment plan.
• Other job duties as requested.

Education Requirements and Other Requirements:

Education Level: Graduate of Registered Nurse Program

Certification/Licensure: Current State of IL Registered Nurse License

Experience Requirements: Experience of 2-3 years in Hospital setting with experience in Case Management. Experience in Home Health or Skilled Nursing Facility would be helpful. Must have excellent physical and emotional health. Must possess good interpersonal skills and demonstrate the ability to communicate appropriately with patients, families, physicians, clinical staff, and community resources. Candidate must have good verbal and organizational skills as well as computer proficiency.