Job Description Summary:The goals of the ambulatory care coordinator are to promote appropriate utilization of services, enhance patients' ability to better manage their health The goals of the ambulatory care coordinator are to promote appropriate utilization of services, enhance patients' ability to better manage their health and disease, and improve the patient's health status, clinical outcomes, and quality of life. The member coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their provider(s).Position Responsibilities
The Ambulatory Care Coordinator is responsible for the coordination of care for patients who have complex medical and/or psychosocial needs, plans for the needs of patients, intervenes, and evaluates outcomes.
Provides a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.
Collaborates with the primary care physicians and interdisciplinary team to develop a plan of care for the highest risk patients.
Collaborates with care teams to identify outcome measures, prepare and analyze outcomes reports, and progress toward program goals as directed.
Assists patients/families, staff and systems to achieve high quality, evidence-based, cost-effective, and patient-focused outcomes.
Facilitates patient access to appropriate medical and specialty providers as well as other care coordination support, including, but not limited to, medication acquisition and management, procedures/tests, appointments, and referrals.
Assists the health care team in identifying and securing appropriate services to address individualized patient needs.
Creates ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
As a key member of the interdisciplinary team, the Ambulatory Care Coordinator will be responsible for collaborating with the care team to ensure a smooth transition of care for patients treated in a facility (inpatients or emergency department), by a specialty physician, or by another healthcare provider.
Responsible for daily review of patient discharge reports and prioritization of follow up calls.
Establishes a communication process with primary care providers and care team members, including but not limited to, regular cadence of collaborative meetings, team meetings, huddles, and appropriate routing of documentation.
Cultivate and support primary care and subspecialty co-management with timely communication, inquire, follow-up, and integration into the care plan regarding transition in care and referrals.
Documents service coordination activities throughout the continuum of care.
Serves as the contact point, advocate, patient liaison and informational resources for patients, families, care teams, payers and community resources.
Educates the patient and care givers about self-management tasks, including but not limited to self-monitoring and problem solving so the patient can gain confidence and greater control of their health status.
Implements, coordinates, monitors, and evaluates appropriate resources using evidenced based standards.
Collaborates with payer case managers for additional services when appropriate.
Collaborates with the primary care provider and care team members by sharing community resources available to patients and maintaining collegial relationships with the entities used most frequently.
Performs patient teaching, patient self-management/self-efficacy coaching and planned care management. Ensures coordination for specialty and other handoffs as necessary.
Coordinates with multiple care managers across the continuum for patient care.
Identifies opportunities for performance improvement
Identifies opportunities for quality improvement
Works with others to develop a plan of action
Implements changes and monitors results of activities.
Other duties as assigned
Compliance Plan and Code of Conduct: Logan is dedicated to the highest ethical standards as it is essential to meeting our commitment to our mission and vision. Individual responsibilities include adhering to our organizational Compliance Plan and Code of Conduct.
Maintains awareness and understands the organization-wide compliance plan. Familiar with and adheres to Logan's published Code of Conduct which provides guidance and expectations regarding confidentiality, conflict of interest, billing, controlled substances, Emergency Medical Treatment and Labor Act (EMTALA), payments for referrals, gifts, anti-kickback laws, safety and health, waste disposal, and compliance with antitrust laws, advertising and marketing, discrimination, insider trading and government requests.
Reports any violation or suspected violation of this Code or other hospital policies or procedures to supervisor, Compliance Officer or through the compliance hotline.
Attends and/or completes mandatory training regarding organizational compliance.
Education and Experience RequirementsRequires:
Current Montana RN License.
Previous experience in caring for chronic disease patients.
Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills.
Proficient in communication technologies (email, cell phone, etc.).
Effective organizational skills and demonstrates ability to maintain accurate notes and records.
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers.
Desired:
3-5 years’ experience in clinical or community health settings.
Previous Care Coordination, Case Management or Home Health experience.
Previous experience with health IT systems and data reports.
Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations.
Ability to speak a relevant second language.
Shift:Day Shift - 8 Hours (United States of America)Schedule Details:Please know schedules and shifts are subject to change based on patient care and department/organizational needs.Logan Health operates 24 hours per day, seven days per week. Schedules are set to accommodate the requirements of the position and the needs of the organization and may be adjusted as needed.Notice of Pre-Employment Screening RequirementsIf you receive a job offer, please note all offers are contingent upon passing a pre-employment screening, which includes:
Criminal background check
Reference checks
Drug Screening
Health and Immunizations Screening
Physical Demand Review/Screening
Equal Opportunity EmployerLogan Health is an Equal Opportunity Employer (EOE/AA/M-F/Vet/Disability). We encourage all qualified individuals to apply for employment. We do not discriminate against any applicant or employee based on protected veteran status, race, color, gender, sexual orientation, religion, national origin, age, disability or any other basis protected by applicable law. If you require accommodation to complete the application, testing or interview process, please notify Human Resources. The Planetree Culture at Logan Health – Whitefish Thank you for your interest in Logan Health – Whitefish where we believe everyone who works at our hospital and clinics is a caregiver. At Logan Health – Whitefish our employees are motivated by our open and supportive culture of caring for the patient and each other. Logan Health – Whitefish was the first hospital in Montana to be affiliated with Planetree International, a non-profit organization setting the global standard for person-centered care. As a Planetree affiliate, we embrace this evidence-based approach partnering with the patient and their family to provide the highest quality patient experience. Logan Health – Whitefish is often recognized as one of the top critical access hospitals in the country and received a 5-star overall rating, the highest designation available for hospitals from the Centers for Medicare and Medicaid Services in 2023. We take pride in providing our quality level of service and continuously work to go above and beyond our stellar reputation. Our people are everything.The amazing providers, employees, and volunteers at Logan Health gift this organization with their innovation, knowledge, and compassion. Together, we're connecting our community to trusted, quality care and helping to improve lives every day.Do you dream of living and working in a beautiful area surrounded by stunning scenery and endless recreation?Are you ready to evolve your career while working alongside passionate, talented, brilliant people?Join our remarkable team and create positive patient experiences every day!