CSKT Care Coordinator in SAINT IGNATIUS, Montana

The Care Coordinator is a member of a patient-centered medical home care team with both medical provider staff and other health care staff (clinical and non-clinical). The patient-centered medical home is a team-based health care delivery model whereby patient treatment is coordinated through the patient's primary care provider to ensure they receive the necessary care when and where they need it, in a manner they can understand. Ensures quality patient-centered care that is consistent with the patient-centered medical home principles, and that is timely, appropriate, cost effective, sensitive and coordinated to achieve desired clinical outcomes. MINIMUM QUALIFICATIONS: - Post-secondary education in mental health related field or 2 years related experience and/or training; or equivalent combination of education and experience. Experience in grant funded activities including fulfilling objectives and completing progress reports and financial reports.- Current, unrestricted Registered Nurse license from the State of Montana or other state.- Graduate from an accredited Bachelor of Science in Nursing (BSN) program, with two years of nursing experience, with at least one (1) year of ambulatory care nursing experience preferred. OR- Currently enrolled in a BSN program. Five (5) years of nursing experience, with at least one (1) year of ambulatory care nursing experience preferred.- Basic Life Support certification. Advanced Cardiac Life Support preferred.- Certification in Care Coordination preferred, required within three (3) years of employment.- Must maintain proper licensure/certification and registration; if required.- Must possess a valid driver's license. Duties include, but are not limited to: - Serves as the point of contact, advocate, and informational resource for patients, care team, family/caregiver(s), and community resources- Develops a plan of care in coordination with the patient, primary care provider, and family/caregiver(s) utilizing clinical quality indicators for all patients on case load, including but not limited to patients diagnosed with cancer, hypertension, diabetes, comorbidities, etc- Regularly evaluates plans of care with patients, providers, and care team as needed, develops mutually agreed upon goals, and provide patient/family education and behavior change coaching- Provides case management, care coordination, and patient education to ensure continuous and comprehensive care for patients on case load- Works collaboratively with the health care team including the clinicians, pharmacists, behavioral health specialist, other nursing staff and medical assistants- Develops plan of care for hospital transitions in order to identify factors to decrease the likelihood of readmission- Ensures case management is implemented and managed to improve continuity and quality of care- Assists with obtaining lab results, medical tests, visit summaries and other information from outside facilities and assists with arranging appointments, procedures, and discharge planning- Increases continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals- Maintains communication with patients on case load concerning treatment progress and diagnostic reports- Engages patients to take an active role in maintaining and/or improving their physical and mental health- Identifies and coordinates referrals to outside facilities and resources in regards to patient need- Completes documentation of all patient encounters and care coordination activities.- Management of nursing division personnel at assigned duty station.- Attends internal and community meetings as assigned and participates in Quality Improvement activities.- Performs job duties of Clinic Registered Nurses/Medical Assistants as needed.- Other duties or special projects as assigned. Request position description for a detailed description and SPECIAL CONDITIONS.