Integrated Care Coordinator Nurse

Job description

Job Description: ESSENTIAL JOB FUNCTIONS Provides first point of clinic contact for all new clients. Explain services available and focus on engagement of client to access services. Completes health screenings, nursing assessments and triage healthcare needs for new and ongoing clients. Participates in team meeting to develop a plan of care to address client needs. Assists clients in navigating the healthcare environment to ensure access to appropriate care. Advocates on client’s behalf with healthcare providers and managed care organizations to ensure timely care. Assists with coordination/access to services that address social determinants of healthcare outcomes: Provides transportation to healthcare appointments, when needed Identifies other needs, when necessary, that ensure access to healthcare Assists in obtaining access to housing (search for housing, applications, financial assistance, communication with landlord), as necessary, when housing status destabilizes health status and presents a barrier to receiving appropriate healthcare. Assists with access to other community resources e.g., public assistance and financial benefits. Develops knowledge base of other healthcare providers in the service area and collaborate, as needed Documents tracking for appointments, medication, and other healthcare needs for assigned clients, as needed Provides education and support wellness activities such as such as healthy eating, physical activity, and healthy behaviors Assists clients who have recently discharged from inpatient treatment, incarceration, residential care, and/or Emergency Department visits to ensure a transition to outpatient care using evidence-based transitional/navigation services to prevent readmissions. Provides caring contacts to clients estimated to be at high risk for suicide to ensure continuity of care. Collaborates with client, family/significant others to develop support networks. The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform job-related tasks other than those specifically presented in this description. EDUCATION Licensed Practical Nurse preferred with current active license to practice in Kentucky. Medical Assistant may be considered based on academic preparation and relevant experience EXPERIENCE Three years of nursing experience in a hospital, physician office, or behavioral care clinic. Experience in community setting or integrated care environment PHYSICAL DEMANDS Position may require lifting of 20 pounds maximum, with frequent lifting or carrying of items weighing up to 10 pounds, or requires significant periods of walking or standing Possible exposure to the threat of bodily harm from clients or families. Normal tasks may involve exposure to blood, bodily fluids, or tissue. Reliable transportation for frequent travel. Within the bounds of their respective job descriptions, all staff are expected to exercise principle-centered leadership, focused on customer service responsiveness, with a continuous quality improvement orientation. Additionally, all staff are expected to develop a working knowledge of and follow all policies and procedures related to safety management and other Joint Commission standards. Time Type: Full time