Clinical Care Coordinator / Education Specialist – RN

Job Description:

The Clinical Coordinator/Education Specialist works closely with the organization and partners as well as various referral sources to ensure patients receive timely, high quality care. The RN ensures that current and potential partners are well educated on the offerings of the organization. This position will include educational meetings with and without physician involvement to effectively educate current and potential clinical partners, and will include the coordination and communication of a patient’s treatment plan and general status to providers during all transitions of care.

Job Duties and Responsibilities:

• Promote timely access to appropriate care for referrals.
• Reduce emergency room utilization and hospital admissions.
• Decrease repetitive and/or unnecessary testing and diagnostics.
• Increase patient comprehension of disease process and management through culturally and linguistically appropriate education.
• Create and promote adherence to oncology and co-morbid care plan, developed in coordination with the patient, oncologist and primary care provider.
• Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
• Increase patients’ ability for self-management and shared decision-making.
• Provide medication reconciliation and education.
• Connect patients to relevant community resources to support the patient medically, emotionally, and financially.
• Schedule and conduct educational meetings with and without physician involvement with key local clinical partners to increase knowledge of the organization’s offerings and offer clinical partners oversight and tracking.
• Oversee and track existing and clinical partners.
• Communicate clinical aspects of care back to clinical integration partners.
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and clinical partners.
• Serve as the point of contact, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
• Continually assess patient’s unmet health and social needs.
• Develop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).
• Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.
• Work with physicians and patients to monitor care and recognize complications.
• Ensure communication of patient status at every transition to oncology and primary care providers as well as specialists when appropriate.
• Facilitate patient access to appropriate medical and specialty providers.
• Educate patient and family/caregiver(s) about relevant community resources.
• Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed.
• Assist with the identification of “high-risk” patients and provide increased monitoring and close follow up.
• Provide feedback

Knowledge and Experience:

• Current NJ RN License
• BSN
• 5+ years’ experience in clinical oncology
• Demonstrated evidence of essential leadership, communications education, and counseling skills.
• Proficiency in communication technologies (email, cell phone, etc.)
• Highly organized with ability to keep accurate notes and records.
• Experience with IT systems and reports preferred.
• Local knowledge of community services and resources preferred.
• Demonstrated proficiency in Microsoft Office applications – Work, Excel, Power Point, preferred.

Physical Demands:

• Frequent travel is required.
• Sit up to 8 hours per day.

Work Environment:

• Professional, business setting.