RN Clinical Care Coordinator

RN Clinical Care Coordinator

Full-Time | Non-Exempt

Weekdays | 8:30 a.m. - 5:00 p.m.

Post Date: 07/24/2024

Open Until Filled

Indian Health Board of Minneapolis is a Federally Qualified Health Care Center and community clinic providing access to quality health care and wellness services. We believe the best care happens when we listen and work together. While promoting and preserving our urban American Indian and Alaska Native traditions and identity, we embrace all people seeking patient-centered, culturally sensitive health care and wellness services.

At Indian Health Board we believe Good Relationships are supported by three interrelated values: Respect for culture - preserving and promoting our American Indian and Alaska Native heritage and identity while embracing all other cultures with acceptance and compassion; Excellence - seeking excellence in all our services, business practices, and community partnerships; Leadership - promoting ethical leadership based on collaboration and mutual respect.

We offer:

• Platinum benefits package available for employees working 30 hours per week or more: Health, Dental, Vision, FSA
• Company paid long term and life insurance
• Generous paid time-off
• Retirement savings plan with employer match

Our mission statement:

"To ensure access to quality health care services for American Indians and other peoples and to promote health education and wellness."

-Respect for Culture Excellence Leadership-

If our beliefs resonate with you, we want you, and encourage you to apply at IHB.

Job Summary

The RN Clinical Care Coordinator will provide direct patient care, educating high risk patients on their diagnosis, disease process and medications, coordinating with the patient and physician in identifying and closing any potential gaps in care or understanding.

Essential Functions

• Provide direct patient care to promote prevention and restoration of health.
• Educate patients and families on disease state based on the chronic or associated conditions identified (asthma, diabetes, hypertension, smoking, obesity, etc.), symptoms, therapy, and lifestyle choices to promote wellness.
• Improve preventative cancer screenings (breast, cervical, colorectal, etc.) through patient education, care coordination, and process improvement.
• Provide medication management and education on action, use, side effects, and nursing considerations of medications related to patient and family teaching.
• Implement strategies to manage patient registries related to medically complex, high utilization, of emergency department, hospital admissions and discharges assisting patients in return to clinic follow up visits and proper use of emergency department.
• Assist with maintaining the MAT patient registry to ensure timely and proper follow-up per the provider and IHB policies.
• Enroll patients into the onsite IHB MAT program, scheduling and completing MAT intakes according to IHB protocols.
• Assist IHB nursing staff with patient triage (phone and in-person), prescription refills, prior authorizations and other duties as needed.
• Provides excellent customer service to patients, peers, leadership, and community partners.
• Acts as Health Care Home Care Coordinator seeking to understand and meet the needs of the patient through respectful and caring interactions with patients, their families, and other health professionals.
• Serve as a linkage between patients and their internal and external healthcare and service providers to improve coordination of services and information flow to ensure effective treatment plans.
• Work with the patient, providers, and HCH Care Team members to develop and maintain an individualized clinical Care Plan for the patient, reviewing regularly and updating as needed.
• Assists patients with the identification, selection, monitoring and documentation of self-management goals, monitoring the patient's progress toward goal achievement and modifying as needed.
• Complete psychosocial assessments with patients and serve as an advocate for the patient to understand needs (i.e. shelter, transportation, childcare, safety) and arrange or coordinate applicable services.
• Identifies clinic and community resources and coordinates appropriate referrals.
• Discusses end-of-life situations, if applicable and health care directives with patients and coordinates these activities with other Care Team members.
• Provide extensive care coordination to identified individuals at high risk for cardiovascular disease and identified individuals with abnormal test results to ensure continuity of care.
• Collaborates with medical and support staff for pre-visit planning.
• Assess and determine the applicable MDH chronic conditions Tier selection.
• Lead disease prevention and health promotion projects as assigned.
• Provide health screenings in the surrounding community as appropriate.
• Track and evaluate program data.
• Complete reports (i.e. monthly board reports, grant-related reports) as scheduled.
• Represent the Indian Health Board at meetings and with other organizations as appropriate.
• Assist in meeting regulatory standards of such organizations as the Joint Commission.
• Maintain patient information in the EHR.
• Participate in Quality Improvement activities as assigned.
• Perform other job-related duties assigned by supervisor.

Knowledge, Skills, and Abilities

• Ability to understand and meet the needs of the patient through respectful, courteous and caring interactions with patients, families and other health professionals.
• Knows, understands and adheres to organizational policy related to the patient's rights for confidential care.
• Knowledge and respect of the American Indian culture and other cultures served by IHB.
• Actively participates and works positively, flexibly and cooperatively in a team effort to accomplish the goals of the Indian Health Board of Minneapolis.
• Manages time effectively and prioritizes task completion to meet deadlines
• Shows initiative and resourcefulness, able to analyze situations and problem solve.
• Excellent written and oral communication skills.
• Proficiency with Electronic Medical Records

Education and Experience

• Registered Nurse licensed in the State of Minnesota
• At least 2 years' experience providing health education, case management, and/or care coordination in the Native American community
• Proven ability to show initiative and solve problems, manage one or more projects, be accurate and attentive to details, meeting deadlines successfully. Must be able to work well independently as well as on a team
• Excellent verbal and written communication skills in a clinical setting, to include EMR documentation
• Exceptional computer skills in WORD, EXCEL and Outlook
• Native nurses encouraged to apply

Physical Demands

The work requires some physical exertion such as long periods of standing, walking, recurring bending, crouching, stooping, stretching, reaching, or similar activities, recurring lifting of moderately heavy items. The work may require specific, but common, physical characteristics and abilities such as above-average agility and dexterity. The work environment involves high risks with exposure to potentially dangerous situations requiring a range of safety and other precautions.

HIPAA

IHB makes reasonable efforts to limit access to and use of protected health information (PHI) by employees to the minimum necessary performance of assigned duties as outlines in job descriptions. This position is access restricted to PHI needed to carry out health care operations.