Job Description

Job Description

Job Description

The Clinical Outreach Coordinator is responsible for facilitating and coordinating care for patients deemed as having an unmanaged chronic illness or chronic utilization of hospital resources by CIN staff, payors and/or providers. The Clinical Outreach Coordinator acts as a liaison between the patient, family and healthcare team; working to assure continuity of care when patients have experienced or at risk of experiencing inpatient services. The Clinical Outreach Coordinator encourages patients to be accountable for their own healthcare; coaching them in activities that promote health and wellness. The Clinical Outreach Coordinator is also responsible for assisting in the management of larger patient populations; participating in performance improvement (PI) activities with the goal of improving quality and reducing costs for these populations. The Clinical Outreach Coordinator primarily works Monday-Friday standard business hours in office, but this may vary based on the needs of the organization.

TASKS AND RESPONSIBILITIES:

Care Management

· Works to help schedule any appropriate transitions of care appointments deemed by program specifications.

• Develops an active Care Management list; managing the frequency of each patient’s care management sessions and whether these be performed via telephonic outreach.
• Performs an initial patient assessment to determine patient’s current medical status, identify barriers and concerns attributed to chronic illnesses.
• Collaborates with patient, family and members of the healthcare team to develop a comprehensive plan of care that addresses the patient’s needs.
• Integrates evidence-based practice into care plans and patient education as appropriate.
• Effectively evaluates the plan of care to determine if the patient is on target for achieving goals. Adjusts plan accordingly as new information becomes available.
• Reports any patient concerns to the Clinical Programs Director for assistance in determining how best to address and resolve these issues.
• Documents all care management activities in the appropriate CIN documentation tool.
• Participates in monthly Complex Patient Care Presentation meetings.

QUALIFICATIONS:

• Current MA/EMT/Paramedic Certification.
• Minimum of three years of clinical experience, including care of patients with chronic disease states.
• Strong interpersonal skills including ability to form collegial relationships with those from diverse backgrounds.
• Strong organizational, critical thinking and problem-solving skills.
• Strong verbal and written communication skills.
• Strong work ethic including ability to manage multiple demands, meet deadlines and work at a rapid pace.
• Ability to work both independently and as part of a team with minimal supervision.
• Competent in basic Microsoft Office skills.
• Previous Case Management experience preferred.

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