Outpatient Care Coordinator jobs in York, PA

UPMC Pinnacle Medical Group, Outpatient Care Management Team is adding an OP Nurse Coordinator I (Registered Nurse, RN) to their team in Hanover/York area. This position will support the Outpatient UPMC Pinnacle primary care providers from patients from UPMC Hanover and UPMC Memorial. The Nurse Coordinator will work a regular, full time daylight schedule Monday through Friday. The RN must have a minimum of 3 years RN clinical experience. 

The Nurse Coordinator I will be a member of the care delivery team who works to establish trusting patient relationships to improve the quality of care, quality of life and improve patient outcomes for patients with complex medical needs. The Nurse Coordinator I uses independent judgment and continued communication with the patient, family, physician, and community resources to assist the patient in attaining a measure of outpatient health. Gas mileage will be paid at the federal mileage reimbursement rate.

HOURS: Monday-Friday Dayshift hours. NO Late evenings. NO weekends. NO major holidays. Autonomous scheduling and case load management

*** Please note this position requires travel to multiple sites as needed and travel to home visits periodically (approx. 5-10 per month). Mileage to home visits is reimbursed. ***

Purpose:
The Professional Nurse Coordinator is a Registered Nurse is a member of the care delivery team. The Professional Nurse Coordinator is responsible for the care of the patient in a global view, accountable for multiple aspects of the patient care package even when patient contact is minimized. The Professional Nurse Coordinator uses independent judgment and continued communication with the patient, family, physician and community resources to assist the patient in attaining a measure of outpatient health. The Professional Nurse Coordinator demonstrates a commitment to the community and to the nursing profession.
 

 
Responsibilities:

• Care coordination for primary care complex patients
• Autonomous scheduling and case load management
• Develops a plan of care for the highest risk patients.
• Performs patient outreaches in person via a home visit or office visit, or by telephone or video visit. 
• Patients with complex needs will be routinely identified through case review, referral from physician practices, and referral from inpatient case management, predictive analytics, and other reliable data sources. 
• This individual plays a pivotal role in the Patient Centered Medical Home (PCMH) by collaborating with the primary care physicians and an interdisciplinary team to develop a plan of care for the highest risk patients. 
• The Professional Care Manager establishes an interdisciplinary approach in working with patients, families, and the care team (e.g. social work, inpatient and specialist care coordinators, pharmacist, etc.) to utilize evidence-based resources to establish appropriate interventions and goals of care. 
• The goals of care management are to maintain clinical stability, promote appropriate utilization of services, enhance patients' ability to better manage their health and disease, and improve the patient's health status, clinical outcomes, and satisfaction.

• Demonstrates accountability for professional development that improves the quality of professional practice and the quality of patient care. Actively participates in practice-based shared governance, goal setting and supports the change and transition process to improve quality of care and the practice environment. Serves as a highly engaged and full partner on the care team and responds willingly to care team member needs for assistance and partnership. Participates in work that improves patient care and the professional practice environment. Adapts to change and demonstrates flexibility with the change process. Provides oversight and supervision to the overall practice environment, assisting all other disciplines and directing clinical/administrative activity as need arises. Demonstrates leadership capabilities with new nursing staff, patient information coordinators, medical assistants and office assistant staff in the daily management of the patient process.
• Formulates goals and a plan of care for patients that involves the patient as partner and considers the individual needs of the patient in a holistic manner. Triages patient situations and coordinates care with physician. Assist physician with all aspects of patient care including assessment, evaluation and education. Provides care for patients in a global, holistic method-responsibility for the patient is viewed in a continual manner, not simply at the time of office/procedural visit. Accountable for outpatient treatment follow up necessary for patient to maintain health in between outpatient visits. Serves as primary nursing resource to patient caseload. Facilitates necessary services outside of the healthcare facility, interacts with homecare and other support services.
• Develops and maintains productive working relationships internally and externally by demonstrating accountability for actions, enthusiasm, motivation and commitment to patients and colleagues. Demonstrates an understanding of cultural differences and holds peers accountable for healthy relationships. Maintains a conscious balance between work and personal life. Models safe work hours, time management and healthy lifestyle. Communicates with peers and management any safety hazards identified in the workplace. Assists the departmental manager (Practice Coordinator or Practice Manager) in patient care planning, operations and innovations.
• Actively participates in department or practice-specific quality improvement efforts. Identifies opportunity for quality improvement to colleagues and management. Takes personal responsibility in improving patient satisfaction with the quality of care and service. Utilizes research and evidence-based practice to support improvement in clinical care, identifies research issues or articles related to clinical specialty or areas of interest. Actively assists and participates in all preparation and maintenance activities for regulatory agency reviews and quality audits. Becomes the patient advocate and voice to the physicians and physician extenders within the practice.
• Ability to establish and maintain positive, caring relationships with executives, managers, physicians, non-physician providers, ancillary and support staff, other departments, and patients/families. Ability to work productively and effectively within a complex environment, handle multiple/changing priorities and specialized equipment. Good clinical judgment with critical thinking, analytical and problem-solving abilities required as related to various aspects of patient care. Critical thinking skills necessary to exercise and to lead others in application of the nursing process. Communication skills that designate the Professional Nurse Coordinator as the voice/advocate for the patient. Mobility and visual manual dexterity. Physical stamina for frequent walking, standing, lifting and positioning of patients.
• Demonstrates critical thinking in the identification of clinical, social, safety, psychological and spiritual issues for the patient care within an episode of care. Practices solid communication skills and is able to articulate and translate the patient's condition to other care providers and to negotiate and make recommendations for changes in patient care and office practices. Patient documentation is comprehensive and promotes communication between caregivers. Incorporates national professional organization as well as business unit and health system's goals to improve patient safety, quality and satisfaction. Creates a caring and compassionate patient focused experience by building healing relationships with patients, families and colleagues.
• Demonstrates knowledge of adult learning principles (and/or teaching children if applicable) and applies in teaching of patients, families, students and new staff. Provides detailed and appropriate teaching to patients and families to effectively guide them through the episode of care both in the office setting and via phone/written communication when at home. Serves as the primary nursing liaison for the development of a total care plan to patient and family. Supports the development of students, new staff and colleagues. May serve as a preceptor for newly acquired staff. May be responsible for coordination of staff training and educational activities. Functions as the senior nursing level assisting in the professional development and maturity of new staff members and ancillary support. Creates an environment of open dialogue, inquiry and continuous development by asking for feedback and improving practice.