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Position Summary:

We have an exciting opportunity to join our team as a Clinical Coordinator.

his position is responsible for care coordination for older adults with diabetes and memory problems across the care spectrum, with emphasis on services incurred 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 expected 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 issues. This position also provides clinical leadership for patient care coordination that is consistent with the philosophy and goals of the institution, the NYUPN Clinically Integrated Physician Network and the Network Integration Department. The position must foster and work in collaboration with internal and external providers, other NYULMC staff and payers to ensure the achievement of high quality outcomes for patients/families.

Job Responsibilities:

• Meet all other expectations and responsibilities of the program/initiative agreement as related to care coordination.
• Initiate/maintain professional development plan including goals for self-improvement and to sustain clinical and NYULMC competencies; attend and participate in program/initiative teleconferences, program enhancement trainings and meetings, as required.
• Assist with orienting and training team members (New hires/interdepartmental initiatives) as requested.
• Participate in the development, promulgation, and implementation of care coordination process standards relevant to service scope.
• Act as 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.
• Oversee and monitor activity by other staff members as related to his/her assigned patients to ensure compliance with associated policies and procedures and timeliness of completion.
• Use the Epic electronic medical record to conduct care coordination activities and comply with associated policies and procedures including those for work flow and consistent documentation.
• Follow evidence based guidelines and contact standards to facilitate closure of gaps in care and encourage use of in network services.
• Interact with relevant stakeholders (health plans, contracted NYUPN practitioners, other providers, Post-acute Care Providers, office staff, etc.) and collaborate with relevant staff to support regular interactions with program/initiative patients.
• Identify patients that have been hospitalized and monitor clinical status.
• Engage patients in taking a proactive role for managing their health, medications, treatment and rehabilitation needs, and follow-up appointments and refer patients to the appropriate community based, health plan or other programs.
• Conduct comprehensive assessments, identify problems/issues, establish goals, implement interventions, reassess needs, establish appropriate timeframe for frequency of follow-up activities, and provide closure and referral services, as appropriate and notify providers of readmissions and significant clinical status changes as appropriate.
• Provide care coordination for patients as assigned, and comply with associated policies and procedures and contractual requirements.

Minimum Qualifications:

To qualify you must

• Fluent in Spanish
• Licensure as a Professional Registered Nurse in NYS with current registration.
• BSN or graduate of an accredited RN program with Bachelors degree in related health care field.
• Relevant clinical experience in ambulatory care, managed care or acute medical-surgical experience in the care of the population targeted for care coordination.
• Spanish speaking. Possesses demonstrated strengths in interpersonal communication, customer service, negotiation, conflict management, creative problem solving, clinical leadership, change management, work process organization and time management. Able to apply critical thinking and clinical expertise toward achievement of specific outcomes. Previously established ability to foster strong collaboration with co-workers, peers, physicians, nursing, and ancillary departmental support staff. Working knowledge of Microsoft Office (Outlook, Word, Excel and PowerPoint) and demonstrated proficiency in managing an electronic medical record such as Epic or a care/case management system.. 

Required Licenses: Registered Nurse License-NYS

Preferred Qualifications:

Two or more years in ambulatory, health plan, or home health setting or ambulatory setting care/case management experience. 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). Epic proficiency. Masters of Science in Nursing or relevant health related field.

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU School of Medicine provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents.

NYU School of Medicine is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.
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