Job Summary
The purpose of the Ambulatory Care Coordinator/Transition Manager is to deliberately organize patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services, ensure that the patient’s needs and preferences for health services are met and information sharing across people, functions and sites are met over time. Care Coordination maximizes the value of services delivered to a patient to by facilitating beneficial efficient, safe and high quality patient experiences and improved health care outcomes. Transitional care provides a broad range of services deigned to ensure health care continuity, avoid preventable poor outcomes among at-risk, complex and chronic condition populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another by using evidence based care planning, comprehensive assessment, coordination of services and critical thinking skills. The Ambulatory Care Coordinator/Transition manager works cooperatively with the primary physician, health care team, patient and their families to improve the individual experience of care, improve the health of populations and reduce the per capita cost of care for populations. The Ambulatory Care Coordinator/Transition Manager will be responsible for identification, screening, assessment, planning, implementation, coordination, monitoring and evaluating health care services provided to the at risk, complex and chronic condition population. The Ambulatory Care Coordinator/Transition Manager will communicate and collaborate with the community as a representative of the EMH Continuum of Care service line. Exhibits the F.I.R.S.T. values (Friendliness, Innovation, Respect, Service and Trust).
Working Conditions, Hazards and Physical Effort
Primarily light work requiring to move or position up to 10 lbs. Long periods in a stationary position and moving around the unit. Works in a well-lighted, ventilated and air conditioned area when in the office; required to go to patient areas and other parts of the Organization for retrieval of information, patient interviews and assessment, meetings and related activities. During home visits possible exposure to disease, infection and physical strain and assault, as well as exposure to blood, body fluids, and tissue. Moderately stressful environment where department’s workload must be completed within prescribed time frames using fixed staffing resources.
Minimum Qualifications or Equivalents
Education: Graduate of an accredited school of nursing.
Experience: Two to five (2-5) years experience in Case Management, Care Coordination and/or Transition Management. Knowledge of Patient Centered Medical Home model, patient-centered care planning and support for self-management, and population health management.
EQUIPMENT USED/SPECIAL SKILLS REQUIRED: Excellent written and oral communication skills, human relations, management, working under pressure, and tact in dealing with the public. Must be able to manage multiple projects. Proficient computer skills required. Preferred knowledge of the Meditech software or equivalent. Must be skilled in medical terminology and diagnosis. Utilizes communication skills with a high degree of effectiveness in working with physicians, hospital staff, consultants and patients/families.
Licenses, Certifications, and/or Registrations
Current KY RN license: BSN, ARNP or ADN working towards BSN within two (2) years. Care Coordination and Transition Management Certification (CCTM) preferred or be certification ready.
Key benefits include:
Health, dental and vision insurance are available upon hire date
Paid Time Off - accruals at 7.08 hours per pay period
Matching Retirement Savings Plan with up to an 8% match
Tuition reimbursement for hard to fill positions
Student loan repayment for certain positions
Cafeteria discount averaging 25%
