Chronic Care Coordinator - REF02A
Company: Kalihi Palama Health Center
Location: Honolulu
Posted on: September 21, 2022
Job Description:
Primary Purpose:The person in this position is a member of the
Patient Centered Health Care Home (PCHCH) team where each team
member plays an integral role in providing patient-centered health
care. The incumbent is responsible in the planning, implementation,
and holistic care coordination of patients with complex and chronic
illness in accordance to KPHC's Care Coordination Model and
evidence based practice guidelines. S/he participates in healthcare
innovation, leads projects, and activities that promotes quality
patient care and improve health outcomes.Essential Duties:
Leads the PCHCH practice team in
team-based communication, planning, developing, and implementing
care coordination activities to improve patient outcomes.Assess the
needs of patients and facilitates referrals and care coordination
with internal and external stakeholders.Provides patient education,
sets SMART goals, and establishes nursing care plan in accordance
to the provider's treatment plan. Identifies gaps in the care of
the patient and ensure that gaps are closed in alignment with
NCQA-PCMH, HEDIS, and Health Plan requirements.Executes effective
interventions to reduce inappropriate ER visits or length of
hospital to improve care and reduce costs.Provides staff training
as it relates to care coordination and chronic diseases as
appropriate.Organizes and coordinates chronic disease patient
classes such as diabetes, asthma, CKD, memory clinic, etc. Works in
concert with other teams to achieve the goals and objectives of the
Patient Centered Health Care HomeImplements policies, procedures,
and processes developed by the PCHCH team.Ensures that KPHC's PCHCH
team asserts changes based on the components of the chronic care
model, KPHC guidelines & PCHCH model and plans for improvements are
implemented. Provides oversight to support staff assigned to assist
in care coordination activities.Prepares monthly report and updates
to the senior management team and executive team as necessaryServes
as a liaison for care coordination to insurance companies and other
organizationsExplores community resources and establishes
partnerships to facilitate improvements.Supports other
multi-cultural projects to enhance patient care.Performs direct
nursing care such as triage, nurse advice and floor duties and/or
covers other departments as necessary.Administrative
Responsibilities
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 adult medicine
care 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.Other Duties: 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. Minimum
Qualification Requirements:Skills/Knowledge: Knowledge and skill in
the delivery of community healthcare. Knowledge of community
resources, how to access such, and an awareness of government
assistance programs. Ability to assess and plan in a multi-cultural
context. Professionalism, sound clinical skills and emotional
stability. Ability to communicate comfortably with multi-ethnic
populations. Flexibility in program development and evolution.
Strong organizational skills. Database creation and maintenance
also desirable Intermediate ability to use MS Windows including
Word, Excel, PowerPoint and Access. Demonstrates autonomy and
self-direction in their work Education: Licensed LPN in the State
of Hawaii required Licensed RN in the State of Hawaii preferred
Bachelor of Science in Nursing preferred Experience: 2 years
general experience providing patient care in community or hospital
setting. 1 year case management experience or experience providing
health education and outreach activitiesKalihi-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.
Keywords: Kalihi Palama Health Center, Honolulu , Chronic Care Coordinator - REF02A, Other , Honolulu, Hawaii
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