Registered Nurse - Care Coordination (Punawai clinic)
Kalihi-Palama Health Center
- Honolulu, HI
- $83,000 per year
- Permanent
- Full-time
- Leads the PCHCH practice team in team-based communication, planning, developing, and implementing care coordination activities to improve patient outcomes.
- Assess the needs of patients and facilitates referrals and care coordination with internal and external stakeholders.
- Provides patient education, sets SMART goals, and establishes nursing care plan in accordance to the provider's treatment plan.
- Identifies gaps in the care of the patient and ensure that gaps are closed in alignment with NCQA-PCMH, HEDIS, and Health Plan requirements.
- Executes effective interventions to reduce inappropriate ER visits or length of hospital to improve care and reduce costs.
- Provides staff training as it relates to care coordination and chronic diseases as appropriate.
- Organizes and coordinates chronic disease patient classes such as diabetes, asthma, CKD, memory clinic, etc.
- Works in concert with other teams to achieve the goals and objectives of the Patient Centered Health Care Home
- Implements policies, procedures, and processes developed by the PCHCH team.
- Ensures that KPHC's PCHCH team asserts changes based on the components of the chronic care model, KPHC guidelines & PCHCH model and plans for improvements are implemented.
- Provides oversight to support staff assigned to assist in care coordination activities.
- Prepares monthly report and updates to the senior management team and executive team as necessary
- Serves as a liaison for care coordination to insurance companies and other organizations
- Explores community resources and establishes partnerships to facilitate improvements.
- Supports other multi-cultural projects to enhance patient care.
- Performs direct nursing care such as triage, nurse advice and floor duties and/or covers other departments as necessary.
- Supports and supervises support staff working with him or her.
- Maintain an awareness of services offered through the clinic and in the community to serve client needs.
- Maintain awareness of legal and legislative issues that may impact service availability.
- Participates in clinic quality improvements activities.
- Work in concert with the adult medicine care team to assess and modify quality improvement strategies.
- Maintains client confidentiality per clinic protocol.
- Develops and implements forms for data collection, tracking and documentation of activities and works with the adult medicine team to determine effective communication strategies.
- Work closely with other clinic staff engaged in activities or projects involving clients as it relates to chronic disease.