The incumbent in this position acts as an advocate for patients serving as the primary point of contact and is responsible for coordinating the care and services of the identified patient populations for an extended period across the continuum of care for both inpatient and outpatient services; promoting effective resource utilization; assuming a leadership role with the multidisciplinary team to achieve an optimal clinical outcome.

Essential Job Functions

General

• Supports and models behaviors consistent with the mission and philosophy of Billings Clinic and department/service.

• Facilitates the coordination of patient care services to assure excellence in patient care and patient flow; includes coordinating care, treatment, and communication among the medical team

            • Follows patient through the care continuum/experience, eliminating operational (such as scheduling, test results, etc.) barriers to services.

• Works closely with other healthcare disciplines to ensure timely appointments, results reporting, financial need referrals, communication, patient care and follow-up

• Facilitates the development, implementation, and adherence to clinical and evidenced based guidelines, as appropriate, to ensure optimal clinical outcomes

• Ensures follow-up on identified patient clinical and non-clinical care, facilitating communication and compliance to care plans (i.e., medication reconciliation, follow-up on care concerns/critical values/core measures, patient care conferences, etc.) Ensures follow up has occurred regarding patient clinical and non-clinical care to include adherence to plans of care, resource utilization, and general progress utilizing care conferences as necessary.

• Works in collaboration with the medical team to develop and implement clinical guidelines. Facilitates the adherence of the guidelines through regular evaluation and auditing of clinical practice.

• Works with care team to assure direct care needs are met, assisting as needed or assigned

• Ensures follow-up in the inpatient and/or outpatient setting on identified patient clinical and non-clinical care, facilitating communication and compliance to care plans (i.e., medication reconciliation, follow-up on care concerns/critical values/core measures, patient care conferences, etc.)

• Demonstrates expertise in educational and resourcing services

• Participates in educational activities related to patient/community, clinical operation, and process issues on an ongoing basis

• Collaborates with other health care providers in developing, implementing, and evaluating educational materials for patients and their families

• Facilitates intra-departmental relationships to provide necessary resources to and for the patient.

• Interfaces with other members/disciplines within the healthcare teams for appropriate referrals/services

• Aware of and assists with financial needs of the patients.

• Identify and access appropriate social services, including resources to assist caregivers to support treatment

• Develop options for complementary and integrative care – IM would not necessarily support this.

• Contributes to an environment of quality and process improvement

• Ensures accurate and timely data collection and entry into patient database as indicated by department guidelines

• Directs and coordinates identified quality assessment and improvement activities to assure quality patient services are monthly provided through audits and reviews other identified evaluation tools

• Ensures patient care activities for the department services are monitored monthly through audits and reviews

• Ensures and enhances facility, safety, and regulatory outcomes

• Complies with all applicable laws, regulations, and accrediting agencies

• Complies with all Billings Clinic policies

• Works in collaboration with Leadership team to ensure hospital and clinic departmental goals and objectives are met.

• Supports the hospital and clinic departmental goals

• Contributes to community activities sponsored by the department

• Develops patient referral services by relationship-building strategies with physicians not related to the department.

• Performs other duties as assigned or needed to meet the needs of the department/organization.

• Works as an active team member and effective communicator

• Demonstrates effective internal and external communication strategies, written and verbal, to assure a collaborative environment

• Ensures appropriate and timely documentation

•Demonstrates a productive work ethic while on duty

• Works consistently as an active team player, inter-and intra-departmentally

• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.

• Maintains competency in all organizational, departmental, and outside agency environmental, employee or patient safety standards relevant to job performance.

• Performs other duties as assigned or needed to meet the needs of the department/organization.

Knowledge, Skills, and Abilities

• Billings Clinic policy and procedures, both organizational and departmental

• Personal computers, hardware, and software

• Microsoft Office Programs (i.e., Windows, Outlook, Word, Excel, etc.)

• Billings Clinic Code of Business Conduct

• Billings Clinic Corporate Compliance Program

• HIPAA and confidentiality requirements

• Patient’s/resident’s rights

• Patient safety standards

• Customer service techniques and Personal Service Excellence (PSE) skills

•  Community resources

• Infection control and safety practices and procedures

• Nursing Theory and practice to assess, evaluation and provide quality patient care

• Advanced nursing assessments and procedures assessment, patient education, provider education, planning, evaluation

• Professional communication skills, both verbal and written

• Strong organizational skills

• Skill in utilizing personal computers with basic computer skills in word processing and data management using Microsoft Office programs

• Conflict resolution

• Incorporate population specific needs into all aspects of communication and patient care; scope of services provided will encompass age groups from infant through geriatric

• Communicate clearly and effectively, both verbal and written

• Establish and maintain collaborative relationships

• Work independently

• Ability to define and implement an evolving role of patient centered care delivered in a complex in integrated health care system which includes setting common goals, merging resources, providing education, and cross training of roles.

• Must be able to work with a variety of diverse and complex patients, families, and both internal and external health care providers.

• Accountable to provide clinically sound information