Brief Description
Why MCR Health?
A career at MCR Health offers exciting opportunities with one of the largest Healthcare companies in the areas we serve. Now, more than ever, we are looking for exceptional people to support our passion to provide "Exceptional Care to Everyone, Every Time", and to support our Mission
to serve everyone. Whether you are providing direct patient care or in other areas of our Company, you can find a home here. We invite you to be part of our Company where you can grow your career and serve with your heart.
In our time of Company growth, we seek a
Patient Care Coordinator.
Work Location: Bradenton, Florida
As Part Of This Role, You Will
The Patient Care Coordinator-Clinical is responsible for actively participating in the successful post-acute care management of assigned patients with complex needs including chronic disease management, active care planning, and management of high-cost patients with multiple barriers, along with open care gaps. Receives assigned patients and takes responsibility for individual patient transition processes for MCR Health patients; from acute to post-acute venues, including skilled nursing and rehabilitation facilities to home. Implements risk-stratified, evidence-based patient transition management processes, targets, and metrics. Actively participates in the management of patients with complex needs including chronic disease management, active care planning, and management of high-risk patients with multiple barriers in successfully managing their disease state. Implements all operational policies and procedures relating to the Care Coordination Department as well as a caring and compassionate impression on all clients of the company,
Job Essential Duties
Identifies the patient’s needs and potential barriers to care through the collection of subjective data from the patient and/or the patient’s family
Maintains a patient caseload consistent with program guidelines
Develop and implement individualized patient care plan with a focus on disease management, patient empowerment, and health care goals; along with taking account of identified discharge needs and potential barriers to care
Assist patients and their families with the navigation of the healthcare system in collaboration with their care team, while addressing open care gaps
Helps the patients and their families by providing linkage to available community resources, as appropriate
Maintains contact with the patients’ assigned PCP as it relates to their active care/treatment plans, along with open care gaps
Review assigned patient cases that require intervention, obtaining guidance from and collaborating with the Patient Care Coordinator (Transitional and Hospital Liaison) regarding daily discharges and new admissions
Participates as an active member of the patients’ in-patient care team; collaborating with patients, family, Providers, clinic staff; and other care team members
Document all encounters and patient-related discussions, telephonic or in-person, in the patient medical record per the organization’s standards
Directly interfaces daily with Hospital Case Management Team members
Conducts hospital, clinic, and home visits as appropriate by following established guidelines, policies, and procedures of the department/organization
Consults and engages with the Clinical Pharmacy Team (Clinical Pharmacist) regarding designated high-risk/ high-cost patients
Notify MCR Health Services pharmacy of pending discharges, communicating medication management needs.
Satisfactorily completes all required staff training and demonstrates compliance with established standardized MCR Health patient transition process from acute to post-acute venues
Maintains all required staff competencies in their respective domain
Participates in departmental and other meetings as assigned
Promotes the use of an EMR patient portal as a method of communication to the care team and accessibility of records
Maintains a clean, clutter-free, and well-organized workspace
Promotes the concepts of “Patients First” and “PCMH”
Performs and embraces all other duties as assigned
Maintains a caseload consistent with program guidelines
Maintains accurate travel documentation
Skills, Knowledge & Abilities
Exceptional customer service skills with the ability to relate to the public and patients, regardless of ethnic, religious, and economic status
Exceptional independent, critical thinking skills
Ability to identify issues, collect and analyze data, establish facts, draw valid conclusions, make recommendations, and implement effective action plans to solve problems
Exceptional communication, interpersonal, and organizational skills
Excellent written, oral, and active listening skills
Strong time management skills with the ability to properly prioritize, manage, and complete simultaneous tasks with frequent interruptions while paying close attention to the details
Ability to work in a fast-paced environment
Possess a high degree of empathy, ethics, initiative, and judgment with the ability to maintain confidence relating to sensitive matters
Ability to work well under pressure with tight deadlines and with a sense of urgency
Ability to be flexible in schedule and adaptable to constant change
Ability to motivate patients and families to participate in their care and maintain adherence to their care plan
Possess excellent clinical record documentation skills
Requirements & Preferences
Graduation from an accredited university with a bachelor’s degree in nursing or associate degree in nursing. An unencumbered license to practice nursing in the State of Florida (RN or LPN) required
Minimum 1-3 years’ experience in Care Coordination, Case Management, or related area within a healthcare inpatient or outpatient setting preferred
Experience in Chronic Care Management desirable
Case Management or related Certification desirable
Experience In Complex Discharge Planning Preferred
Proficient in Microsoft Office products, EPM, and EHR software preferred
Ability to function autonomously while keeping team members and leaders informed
Possession of a current Florida State driver’s license and a registered, insured vehicle as periodic travel may be required to effectively service patients
Must have proof of vehicle insurance if the position requires driving
Must be able to work a flexible schedule
Physical Demands & Equipment Use
Physical demands described here represent those that must be met by an employee to successfully perform the job's essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
While performing the duties of this job, the employee is regularly required to drive, sit, use hands or fingers, handle or feel objects, tools, and controls, and talk or hear
The employee frequently is required to walk, stand, and reach with hands and arms
The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl
The employee must occasionally lift and/or move up to 25 lbs.
Must be able to maintain a professional manner, tactful when voicing an opinion (constructive criticism) when necessary, in a manner that would not demean the profession, clinic, and self
Must have the ability to communicate and establish effective working relationships
Must be able to coordinate several activities to quickly analyze and resolve problems
Understands that work can be stressful, and long hours are often required
This job is not limited to the activities described above and this job description may be amended by management as deemed necessary.
Requirements
What you need to bring to this role:
- Graduation from an accredited university with a background in science, including a BA or BS in Public Health, Behavioral Science or similar degree; or a Licensed Nurse with a minimum of 5 years of clinical experience in both inpatient and ambulatory care settings in provision of direct services to patients preferred.
- A minimum of 3 years of experience in care coordination, case management, or related area may substitute for the educational requirement above.
- Experience in Chronic Care Management desirable
- Case Management or related Certification desirable
- Experience in complex patient care planning preferred.
- Proficient in Microsoft Office products, EPM, and EHR software preferred.
- Ability to function autonomously while keeping team members and leaders informed.
- Possession of a current Florida State driver’s license and a registered, insured vehicle as periodic travel may be required to effectively service clients.
MCR Health Services is a drug free workplace. All job applicants selected for employment are required to submit to a pre-employment drug test.
Summary
The Patient Care Coordinator is responsible for actively participating in providing education, information and resources to Emergency Department “high utilizers” patients with complex needs, and multiple barriers. This position will act as a first point of reference to identify MCR patients to coordinate and assist with the decrease utilization by capturing demographics, Primary Care Provider, assigning eligible patients to a Care Coordinator, and works closely with MCR clinics to arrange appointments.
- MCR Health is a drug-free workplace. All job applicants selected for employment are required to submit to a pre-employment drug test and background check.
