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For Applications please call or visit:
Rice Medical Center
600 S. Austin Road
Eagle Lake, Texas 77434
979.234.5571 x1002
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Clinical Care Initiatives Coordinator - Job Description Full-time (40 hours/week)
Position Summary
The Clinical Care Initiatives Coordinator is responsible for the ongoing clinical management of the clinics' participation in Accountable Care Organizations, Care Management programs, Value Based programs, Managed Care Organization programs, transformational programs and/or Population Health Management programs. The Clinical Care Initiatives Coordinator (CCIC) will lead RMA's transformation and performance improvement initiatives. The selected candidate will guide the practice in achieving targeted goals that include improved quality, efficiency and utilization. The CCIC is accountable for driving practice progress toward desired change and performance improvement, while meeting savings goals set for the practice. The CCIC coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician.
The CCIC reports directly to the Practice Manager. The CCIC will act as a mentor to other clinicians on the team. As the clinical point of contact for the clinics, the CCIC will be responsible for communicating progress towards achievement of targeted goals.

Primary Responsibilities
" Accountable for successful deployment of RMA's clinical support programs at the practice level, including but not limited to, introducing and educating the clinics on the value/use of reporting tools, patient registries and delivery of reports
" Build and effectively maintain relationship with leadership and key clinical influencers actively involved in all programs
" Coordinate, consolidate, and streamline all current and future quality &/or incentive-based programs/activities: ACO, CCM/TCM, DSRIP, MCO reporting, MIPS, MU, etc.
" Regularly facilitate efficient, effective practice improvement meetings with the clinics to monitor, present, and discuss progress on the action plan and goal achievement
" Develop strategies; based on performance analysis, for improvement that includes specific outcomes and metrics to monitor progress to a goal and make recommendations for improvement
" Design action plans and implement appropriate performance improvement initiatives designed to assist the practice in achieving contractually required milestones/goals
" Monitor and review the progress of the practice in goal achievement and insure the practice is accountable for successful completion
" Use data to analyze key cost, utilization and quality data and interpret results to assess the performance of the practice
" Assist clinics in creating work flows to optimize care delivery, introduce best practices improvements, and evaluate outcomes to reach mutual goals
" Educate & deploy technology tools to support the various programs
" Integrate technology tools into practice workflows
" Build and effectively maintain relationships with team members in the RMA/RMC clinical and administrative staff, as well as full Medical Staff
" Consult and partner with appropriate internal and external resources to identify organizational and structural challenges hindering achievement of desired program outcomes
" Collaborate with internal and external resources including the quality management and PI teams, hospital clinical teams, and behavioral health teams to support integrated PCP driven care
" Work closely with other areas including the various programs and services development, systems, outcomes research and reporting, claims management, and payer contracting to ensure customer needs are met while meeting internal objectives.
" Develop and manage the tactical plan for implementation of disease management programs. This includes development of timelines and documentation regarding the implementation process.
" Work to align and integrate care/disease management programs and population health services to augment the clinic's capabilities, support their care management efforts and add value to the patient care experience
" Assist and support department leaders in summarizing and disseminating experience - related learning's by way of team updates, written reports / articles, and / or presentations as called for by directors
" Participate in training necessary to keep abreast of current program changes, regulations, and updates
" Attend and actively participate in all care management and performance program-related training and meeting activities

Care Coordination Responsibilities (Oversight &/or Hands-on)
" Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population
" Manage the implementation and day-to-day operations of the organization's disease management program
" Implement an effective internal tracking system for identified patients
" Coach patients/families toward successful self-management of their chronic disease
" Utilize tools and documents that support a guided care process, collaborate with patients/families toward effective plans of care
" Provide effective communications to improve health literacy
" Develop care plans based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed
" Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time
" Promote healthy behaviors in all populations and ensure navigation assistance with community resources
" Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists
" Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
" Serve as the contact-point, advocate, and informational resource for patients, families, care team, payers, and community resources
" Ensure effective tracking of test results, medication management, and adherence to follow-up appointments
" Develop systems to prevent errors (e.g., effective medication reconciliation and shared medical records)
" Facilitate and attend meetings between patients, families, care team, payers, and community resources, as needed
" Ensure patients are setup for wellness visits, and all information is collected to achieve success in the applicable program(s)
" Update &/or schedule annual testing as needed to achieve success in applicable program(s).
" Follow-up to ensure patients keep appointments; assist with rescheduling when necessary
" Ensure effective utilization of Patient Portal

Minimum Qualifications
" A bachelor's degree, advanced degree in health-care field, or current licensure as a Registered Nurse
" 4 years experience in clinical or community health settings preferred: nursing, the managed care or the pharmaceutical industry
" Strong project management skills. Demonstrated ability to manage complex, multidisciplinary projects
" Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills
" Effective organizational skills and demonstrates ability to maintain accurate notes and records.
" Previous experience with health IT systems and data reports preferred
" Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred
" Cultural and language sensitivity and awareness
" Ability to speak a relevant second language preferred
" Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required
" Strong customer service orientation
" Detail oriented, with excellent verbal, written, interpersonal and presentation skills
" Strong interpersonal and negotiation skills
" Proficient in communication technologies (email, cell phone, etc.).
" Computer skills including the Microsoft Office products
" Travel between locations and in community required

Position Competencies
" Core values consistent with a patient/family-centered approach to care.
" Demonstrates professional and effective written and verbal communication skills.
" Demonstrates a positive, respectful attitude and professional customer service.
" Acknowledges patients' rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
" Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
" Recognizes and responds to opportunities for improvement.
" Demonstrates continual learning skills, effects changes in approach to care based on established, evidence-based practice.
" Demonstrates professional practice behavior.
" Provides mentoring/coaching of other population health and care coordination team members.
" Cultivates effective partnerships, effectively collaborates with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members).
" Demonstrates understanding in use of IT resources and patient databases.
" Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.

For Applications please visit or call:
Rice Medical Center
Sanjuana Martinez
Human Resource Department
600 South Austin Road
Eagle Lake, Texas 77434
979.234.5571 X-2011
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