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Northern Light Health

Department: Care Coordination

Position is located: Northern Light Eastern Maine Medical Center

Work Type: Full Time

Hours Per Week: 40.00

Work Schedule: 8:00 AM to 4:30 PM

Summary :

Oversees the coordination of care for patients hospitalized with Congestive Heart Failure and Myocardial Infarction. Provides comprehensive education regarding the disease process using multiple modalities to ensure understanding. Serves in an expanded nursing role to collaborate with the Care Team to provide a model of care that ensures the delivery of quality, efficient, and cost-effective healthcare services. Integrates modified evidence based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare. Works closely with inpatient and ambulatory care management to offer seamless transitions of care.

Responsibilities :

• Monitor patient progress during acute care setting to promote early interventions to reduce length of stay and minimize readmission. Provides individualized education related to specific disease process, associated treatment modality, and agreed plan of care for patient and family. Initiates goals of care conversation with patient and family.
• Provide safe transitions throughout the continuum of care by collaborating with the care team, patient, and family to develop and manage the plan of care, while promoting patient independence and self-management.
• Demonstrate the ability to negotiate and influence individual and group decision- making.
• Adapt to a fluid, dynamic and rapidly changing environment.
• Demonstrate leadership qualities in the areas of time management, problem solving, decision making, prioritization, delegation, organization, skilled written/verbal communication and listening skills.
• Monitors laboratory results, diagnostic tests, utilization patterns and other metrics in collaboration with the interdisciplinary team to monitor quality and efficiency results for assigned population.
• Provides up-to-date coordinated patient centered care to the multidisciplinary care team.
• Collaborates with Inpatient/Outpatient Care Management staff to facilitate smooth transitions across the healthcare continuum.
• Discharge planning confirmation (inpatient CM will continue usual coordination, while HF navigator confirms best plan for the patient), disease process education, medication reconciliation prior to discharge, ensure patient has all prescriptions to include elimination barriers to obtaining, and set follow up appointment.
• Other Duties.

Other Information :

Competencies and Skills

• Basic Life Support
• Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
• Electronic medical record software.
• Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
• Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one's behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively.
• Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit.
• Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level.
• Exercises Sound Judgment & Decision Making: Understands and processes complex information, which allows for appropriate and accountable conclusions. Does not react too quickly or slowly. Balances facts, goals, and potential approaches taking the appropriate criteria into account. Makes active decisions and commits oneself by communicating confidently and respectfully.
• Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
• Ability to understand the language used to precisely describe the human body including its components, processes, conditions affecting it, and procedures performed upon it.
• Spreadsheet application with the ability to use calculations, formulas, graphing tools, pivot tables, and a macro programming.
• Word processing, spreadsheets, data entry, database experience and other computer related skills.
• Email application with the ability to manage email as well as calendars, managing tasks and contacts, note taking, journaling, and web browsing.
• Presentation software with the ability to create presentations with the ability to incorporate animation, audio, video, time delays, as well as designing themes and variants with animations and effects.
• MS Teams
• Word process application with the ability to create and edit documents, format, use tables, apply footnoting, create table of contents and mail merge techniques.
• Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
• Provides Patient-Centered Care: Demonstrates understanding of patient care quality and service as organizational priority. Proactively supports change to improve patient experience and results. Exhibits the ability and willingness to find out what the patient wants and needs and to act accordingly, taking the organizational and outside resources into account. Cooperates, collaborates, communicates, and integrates care within and between teams to ensure that care is continuous and reliable.

Credentials

• Required Registered Nurse

Education

• Required Associate's DegreeBachelor's Degree in Nursing Preferred.

Required Experience

• 3 year/years of Relevant Work Experience

Working Conditions

• Potential exposure to diseases or infections.
• Prolonged periods of sitting.