Job Posting

Chronic Care Coordinator - RN - Clinic
Hot Springs County Memorial Hospital
Job Description
DEPARTMENT: Red Rock Family Practice
SUPERVISOR: Practice Manager


APPROVED BY: Chief Executive Officer DATE: December, 2018
In accordance with the Hot Springs County Memorial Hospital Personnel Policy and Procedure Manual and the requirements of our accrediting bodies, the employee will: support the mission "Partnering with our community for quality health and healing", the five core values "Ownership, Always better than yesterday, Service first, Integrity, and Stewardship of our resources (OASIS). Our behavior creates our OASIS - a place where we can find safety, sustenance, and a pleasant change from the usual. and vision of "being the hub for the development and provision of quality health services while ensuring the viability of Hot Springs County Memorial Hospital as a valued healthcare partner in the community."

The established priorities of Quality, Service, Finance, People, and Growth, will be utilized in decision making. Furthermore, the employee will demonstrate the ability to manage time, maintain a safe and clean environment; practice confidentiality; treat all persons with respect and professional courtesy; accept change; accept and provide constructive feedback; work as a team player and adhere to the infection control, fire and safety, disaster and hazardous waste policies. The employee must also demonstrate the competencies for their position, and adhere to policies and procedures of their department. The employee will participate in quality improvement activities.

The following is a list of minimally required behaviors to assist the employee in partnering with our community:

Accepts responsibility for actions, attitudes and health. Doing things right the first time, every time for excellent results. Accepts ownership of mistakes and takes constructive action to avoid repeating mistakes. Works with empowerment to the highest potential both as an individual and as part of the team. Unsatisfied with the status quo or just being "good." Contributes to an environment that encourages creative thinking. Shares ideas and opinions, and supports opportunities to learn and grow.

Always Better Than Yesterday
Performs at the highest level, always learning and looking for ways to improve, with an unwavering focus on safety. Celebrates and encourages the contributions of one another.
Constructively challenges the status quo by being flexible, adaptable and embracing change as a key element of our future success.

Service First
Doing our best every day to anticipate and exceed the expectations of patients, providers and co-workers. Understands excellence is the result of team effort. Creates legendary experiences.

Does the right things. Consistently open, honest, trustworthy and ethical. Demonstrates respect for patients, their families, staff, providers and the community.

Stewardship of Our Resources
Strives to care wisely for our human, financial and natural resources. Strengthens HSCMH as a partner in the community.

Position Summary: The RN-Chronic Care Coordinator is responsible for providing outreach, disease management/case management, care coordination, education/training and motivational support to patients, referral sources and the community to encourage quality outcomes, smooth transitions and coordination of care across the health continuum, encourage healthy lifestyle choices and reduce long term effects of chronic illness. This position is accountable for working with and representing our clinic across multiple constituents

1. Provide outreach, disease management, education and other needed clinically based activities to patients managing various chronic health conditions and to referral sources and community. Assess and identify participant's readiness, willingness and ability to change, identify their coaching, support and educational needs, determine and provide relevant community and/or health care resources to support solutions; provide educational tools to promote self-management
2. Develops interventions and sets goals for behavioral modification within the scope of nursing practice.
3. Conducts health and wellness coaching sessions to assist participants in making lasting changes to their health and wellness. Monitor and document the patient's progress toward his or her optimal level of wellness. Promotes wellness and provides education regarding preventative care measures.
4. Promotes wellness and provides education regarding preventative care measures.
5. Acts as a liaison between referral sources, facilities and outside entities to prevent and/or resolve continuum of care issues
6. Communicates, as needed, with service delivery partners, providers and other health professionals to provide care coordination so as to ensure the plan of care facilitates the efficient use of health care resources.
7. Demonstrates skills in effectively coordinating and monitoring care to promote quality and cost-effective outcomes.
8. Proactively follows up with patients discharged from all hospitals, rehab facilities and emergency rooms to ensure patient has an appointment with their provider and reviews any unmet needs prior to the upcoming appointment.
9. Analyzes clinical data generated from EHR/Registry system and identifies patients who have gaps in care and utilizes risk stratification intervention metrics for tracking and care coordination purposes.
10. Remains current on industry trends, best practice operational models, and changing patient and provider needs.

The above duties are intended to describe the key aspects of the work performed by individual(s) assigned to this position. They are not to be construed as an exhaustive listing of requirements relative to the position. Therefore, the employee may be required to perform other duties as assigned.

11. QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must be able to travel between three clinic locations when directed and as appropriate.

1. Unencumbered Registered Nurse in the State of Wyoming.
2. 3 years supervisory clinical experience.
3. Previous work experience with educating patients and patient goal setting preferred

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write policies and procedures that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors.

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and is knowledgeable in metric, apothecary and household measurements and can convert from one system to another.

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to modify care based on the developmental / functional age of the patient as well as that of the patient's ethnic background.


 Must have a current Wyoming Nursing License in good standing

Ability to act as a patient advocate. Ability to interact with patients, families, visitors and co-workers. Ability to interact assertively and tactfully when dealing with conflict and in group solving activities. Ability to demonstrate a professional, open minded approach in identifying problems and resolving problems/conflicts.

Age Specific:
Must be able to provide care according to the developmental level and or chronological patient served. This includes, but is not limited to, identifying the needs and abilities of each patient, and demonstrating an understanding of how a patient's chronological and developmental age influences his/her need for adaptations related to his/her abilities. Also, an understanding of how a patient's age impacts his/her ability to deal with and adapt to the care needed/provided is required. General census of neonatal to geriatric patients.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While filling this position, the employee must regularly lift and or move 10 pounds and occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this position include close vision, distance, vision, color vision, peripheral vision, and depth perception. This position also requires walking or standing to a significant degree. This position also requires reaching, handling, fingering, feeling, talking, and hearing, stooping, bending, crouching, and working with equipment.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee is subject to inside and possibly outside weather conditions. The employee is also subject to exposure to blood and body fluids, proximity to moving mechanical parts, electrical shock, exposure to burns and radiant energy, exposure to toxic chemicals and biological agents.

Additional Information
Position Type : Full Time
Shift : Day

Contact Information
David Serle - Clinic Manager
Phone: 307-864-5534

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