Nurse Care Coordinator - Chronic Disease
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Description
Department: Clinical Services
Immediate Supervisor Title: Clinical Director
Job Summary: The Nurse Care Coordinator - Chronic Disease position provides assistance to the physicians and support staff by coordinating care and services for patients in order to maximize use of available resources and to offer complete preventative care to those in need. Working within the Registered Nurse scope of practice, and in concert with the Primary Care Provider, patient, caregivers, family members, other members of the Care Management Team and the community to coordinate a full continuum of health care services considering the holistic needs of the member, inclusive of unique social and cultural dynamics. This position will collaborate with Care Managers while instructing individuals and families in the community about health education and disease prevention utilizing a team-based approach. The Chronic Disease Care Coordinator will work to provide medical case management services to eligible patients within the Federally Qualified Health Center (FQHC). This nursing position works to address the needs of the population served by assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required and using communication and available resources to promote quality, cost-effective health outcomes. In addition, this position will support HCCH goals and objectives in meeting performance improvement targets for various initiatives, data analysis that supports care management, standardized plan of care expectations, and patient team development and perform other duties as assigned to support the development of the network.
Job Responsibilities and Role on Care Team
This position will provide services to patients within the organization by following applicable guidelines and best practice care models.
This position will function as an integral member of an interdisciplinary team which will include the following: medical provider, behavioral health clinician, clinical pharmacist, supportive services staff, and additional departmental staff.
This position description should not be interpreted as all-inclusive. It is intended to identify the major responsibilities and requirements of this position. The incumbent may be requested to perform job-related responsibilities and tasks other than those stated in this description.