AMVETS Jobs

+-----------------------------------------------------------------------+ | Primary Purpose: | | | | The person in this position is a member of the Patient Centered | | Health Care Home (PCHCH) team where each team member plays an | | integral role in providing patient-centered health care. The | | incumbent is responsible in the planning, implementation, and | | holistic care coordination of patients with complex and chronic | | illness in accordance to KPHC's Care Coordination Model and evidence | | based practice guidelines. S/he participates in healthcare | | innovation, leads projects, and activities that promotes quality | | patient care and improve health outcomes. | +-----------------------------------------------------------------------+ | Essential Duties: | | | | - 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 and 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. | | | | Administrative Responsibilities | | | | - Supports and supervis s 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. | | | | Regular and reliable on-site attendance is required. | +-----------------------------------------------------------------------+ | Other Duties: | | | | Perform other related duties as assigned | | | | Observe safety and security procedures; determine appropriate actions | | beyond guidelines; report potentially unsafe conditions; use | | equipment and materials properly. | +-----------------------------------------------------------------------+ | Minimum Qualification Requirements: | | | | Skills/Knowledge: | | | | Knowledge and skill in the delivery of community healthcare. | | | | Knowledge of community resources, how to access such, and an | | awareness of government assistance programs. | | | | Ability to assess and plan in a multi-cultural context. | | | | Professionalism, sound clinical skills and emotional stability. | | | | Ability to communicate comfortably with multi-ethnic populations. | | | | Flexibility in program development and evolution. | | | | Strong organizational skills. | | | | Database creation and maintenance also desirable | | | | Intermediate ability to use MS Windows including Word, Excel, | | PowerPoint and Access. | | | | Demonstrates autonomy and self-direction in their work | | | | Education: | | | | Licensed LPN in the State of Hawaii required