Position Summary:
We have an exciting opportunity to join our team as a Clinical Care Coordinator.

This position is responsible for care coordination across the continuum of health care delivery with emphasis on services received outside the inpatient hospital setting. Care coordination includes assessing healthcare needs, identifying problems and opportunities for improvement, implementing interventions, managing the patient care transition process, assisting patients throughout care episodes, coordinating and facilitating care for patients with complex and chronic conditions, and promoting evidence-based healthcare services. This position provides services to support program outcomes of reduced admissions/readmissions, reduced emergency department visits, improved medication compliance, reduced gaps in care, improved patient care coordination, and increased patient satisfaction with the health care experience. The individual in this position serves as a clinical liaison and must demonstrate awareness and recognition of the plan of care across the continuum in order to direct patient care. This position also provides clinical leadership for patient care coordination that is consistent with the philosophy and goals of NYU Langone Health, the NYUPN Clinically Integrated Physician Network and the Network Integration Department. The position must work in collaboration with internal and external providers, other NYULH staff and insurance payers to ensure achievement of high quality outcomes for patients/families.

Job Responsibilities:

• Provide care coordination for patients as assigned in compliance with appropriate policies and procedures and contractual requirements
• Conduct comprehensive assessments, identify problems/issues, establish goals, implement interventions, reassess needs, and establish appropriate timeframe for frequency of follow-up activities.
• Provide closure and referral services as appropriate and notify providers of readmissions and significant clinical status changes as appropriate
• Engage patients in taking a proactive role for managing their health, medications, treatment and rehabilitation needs, and follow-up appointments. Refer patients to appropriate community based, health plan or other programs.
• Identify patients that have been hospitalized and monitor clinical status
• Interact with relevant stakeholders to support regular interactions with program patients (Ex. - health plans, contracted NYUPN practitioners, other providers, Post-acute Care Providers, office staff, etc.)
• Follow evidence based guidelines and contact standards to facilitate closure of gaps in care and encourage use of in network services
• Oversee and monitor activity by other staff members in relation to assigned patients to ensure compliance with associated policies and procedures and timeliness of completion.
• Be a professional role model to all levels of staff by considering the needs and behaviors of specific patients in a culturally competent manner and incorporating expertise, critical thinking and related experience in care of patients and families
• Participate in the development, communication and implementation of care coordination process standards relevant to service scope
• Assist with precepting and training team members as needed (new hires and during implementation of new workflows)
• Initiate/maintain professional development plan including goals for self-improvement and to sustain clinical and NYULH competencies; attend and participate in program/initiative teleconferences, program enhancement trainings and meetings as required

Other duties as required

Minimum Qualifications:
To qualify you must have a Current license to practice as a Registered Nurse in New York State and Florida
Bachelor of Science in Nursing
3-5 years of clinical experience in the ambulatory, managed care, or medical-surgical setting, with experience caring for the population targeted for care coordination
Strong interpersonal communication skills, customer service skills, problem-solving skills
Strong time management skills and ability to work independently
Strong critical thinking and creative problem solving skills
Ability to be a clinical leader and change agent
Able to collaborate with staff across the organization, including physicians, social workers, etc.
Working knowledge of Microsoft Office (Word, Excel, PowerPoint, Outlook)
Comfortable working in an electronic health record, particularly Epic.

Required Licenses: Registered Nurse Lic- Florida, Registered Nurse License-NYS

Preferred Qualifications:
2 or more years of experience working in a health plan, home health care, or ambulatory setting as a care manager
Membership in care/case management and/or related professional organization
Certification in Case Management, American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or Certified Professional Healthcare Quality (CPHQ).
Masters of Science in Nursing or relevant health-related field.