The Ambulatory Care Coordinator is a member of the Ambulatory Care Management team caring for the patient and ensuring the patient's individual needs are identified and addressed in a timely manner. The Ambulatory Care Coordinator acts as the patient advocate for those discharged from post-acute care, works to address primary physical and social needs including identifying and coordinating community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family upon discharge. The Ambulatory Care Coordinator is responsible for coordinating care to obtain desired health outcomes, improve self-care abilities, decrease cost of care, and provide extraordinary patient care in the process. This position applies principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and adjusts patient coordination accordingly. The Ambulatory Care Coordinator reports to the Director of Care Coordination and works collaboratively with the Ambulatory Care Management Team to help manage patients in the community environment.

RESPONSIBILITIES:

* Through weekly meetings, will develop collaborative relationships with skilled nursing facilities (SNF's) to influence patient outcomes, risks for readmissions and longer than necessary length of stays.

* Track and monitor progress of BSMG, ACO and other value-based patient populations discharged to SNF.

* Contact patients, caregivers/family after SNF discharge per department protocols, performing a thorough outreach, reviewing discharge instructions, medication reconciliations and identifying unmet needs, as well as facilitating post discharge follow up with PCP

* Actively coordinates access to primary and specialty care providers including behavioral health, keeping providers and Ambulatory Care Managers informed of SDOH needs of patients so that effective treatment plans can be created.

* Evaluates and refers patients to the Ambulatory Care Manager, per department protocols.

* Follows treatment plans of patient as written by provider and/or Ambulatory Care Manager and where appropriate, evaluates patient in the home environment, to facilitate the patient's ability to improve self-management skills.

* Initiates/contributes to team discussions regarding home management of assigned patients including facilitation of home care referrals where appropriate.

* Provides expertise in linking patients with community resources services which promote sound health, lifestyle, and well-being such as prescription assistance, Meals on Wheels, DOH and insurance services etc. Follows through to determine efficacy.

* Educates and aid family members in understanding, dealing with, and supporting the patient with a chronic illness and end of life expectations. Where appropriate, facilitate discussion with patient and family members on advance directives.

* Communicates clear, complete, and accurate documentation in EMR and follows system approved protocols to ensure that all those involved in a client's care have access to necessary information to plan and evaluate their interventions. Perform tasks necessary for data collection, maintaining records, developing, and utilizing workflows per department protocols.

* Schedules timely and appropriate office and follow-up visits at/with and for other health care providers such as dentists, public health, social services, or any other outreach workers as needed to provide comprehensive and quality care for patients and performs other job duties as assigned.

* Performs other tasks as assigned.

QUALIFICATIONS/REQUIREMENTS:

5 years of experience in Skilled Nursing and/or ambulatory practice experience required. Experience working as a care manager from ambulatory/ post- acute setting preferred. Current NYS LPN License. Good verbal and communication skills. Organizational skills a must. Competency in electronic medical records preferred. Microsoft excel skills is required. Bi-lingual preferable.

EDUCATION:

Licensed Practical Nurse

OTHER:

If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

About Us:

Bon Secours Charity Medical Group

Bon Secours Charity Medical Group, part of Bon Secours Charity Health Systems (BSCHS), a regional network of more than 120 primary care physicians and specialists from a broad array of medical specialties. BSCHS, a member of WMCHealth Network, includes Good Samaritan Hospital in Suffern, NY, Bon Secours Community Hospital in Port Jervis, NY and St. Anthony Community Hospital in Warwick, NY.