Ambulatory Care Coordinator Licensed Practice Nurse

Job Details:

Primary Function/General Purpose of Position

The primary responsibility of the Ambulatory Care Coordinator working under the oversight of assigned Ambulatory Manager and Supervisor is to promote the health and welfare of assigned patients through face to face and/or phone outreach and e-mail communications. The Ambulatory Care Coordinator is a member the ambulatory care team in caring for the patient and ensuring the patient's individual needs are identified and addressed in a timely manner. The Ambulatory Care Coordinator acts as the patient advocate to address primary physical and social needs including assessing and linking community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family.

Employment Qualifications

Licensed Practice Nurse with 5 years acute care and/or ambulatory practice Experience.

Experience working with care managers from ambulatory/acute care setting.

Good verbal and communication skills and organizational skills a must.

Competency in electronic medical records desirable.

Bi-lingual preferable.

Essential Job Functions

Accountable for contacting patients, caregivers and families to ensure preventive

services are received by assigned patients.

Accountable for contacting patients, caregivers/family after hospitalization to

assess unmet needs and to facilitate post hospital follow up with PCP.

Decrease identified care gaps by working with primary care offices to obtain timely

appointments for assigned patients including post-hospital discharge follow up and Annual Wellness Visits, where appropriate.

Understand and apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and refer to Ambulatory Care Manager accordingly.

Provide care coordination services for patients requiring chronic care management.

Ensure that appropriate patients receive annual physical exam and/or annual health risk assessment (HRA) including completion of required documentation by payer contract.

Evaluates and refers patients to the Ambulatory Care Manager, as appropriate, when acuity changes

Follow treatment plans of patient as written by provider and/or Ambulatory Care Manager.

Where appropriate, assesses patient in the home environment and assist in the evaluation of the patient's needs in their home, in order to facilitate the patient's ability to improve self-management skills.

Initiates/contributes to team discussions with regard to home management of assigned patients including facilitation of home care referrals where appropriate.

Where appropriate, facilitate discussion with patient and family members on advance directives.

Provides expertise in linking patients with community resources such as prescription assistance.

Assist patients in navigating social and health services such as enrollment in social security, Medicaid, Medicare and other appropriate insurance plans.

Assesses and assist patient's safety needs in home, ie. fall risk and order equipment where necessary to promote patient independence.

Assist with self-management of medication, ie. setting up medication boxes if needed.

Refer patient or family to community resources for housing or treatment to assist in recovery from chronic illness, and following through to ensure service efficacy.

Educate and aid family members to assist them in understanding, dealing with, and supporting the patient with a chronic illness and end of life practices.

Interview clients about activities of daily living to determine needs and link with community resources where appropriate.

Reviews and updates Provider and Ambulatory Care Manager of patients' living conditions and ability to adhere to plan of care and coordinate treatment goals.

Assess, monitor, and evaluate, the patient's progress in the home with respect to treatment goals.

Documents findings in health care record following System approved protocols.

Perform the tasks necessary for collecting data, maintaining records, developing and utilizing assessment and measuring tools relative to patient care and wellness practices.

Obtain and coordinate access with primary care providers and other specialty providers including behavioral health ensuring necessary records and documentation of referrals are completed and reconciled.

Educate patients on availability of resources for primary care and acute care along with alternative community programs and services that promote sound health, lifestyle and well-being.

Schedule timely and appropriate office and follow-up visits at/with and or other health care providers such as dentists, public health, social services, or any other outreach workers needed to provide comprehensive and quality care for patients.

Be able to work independently with minimal supervision.

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