Care Management Coordinator

1 week ago

Abbotsford, British Columbia, Canada Fraser Health Full time
Job Summary

We are seeking a highly skilled and experienced Care Management Coordinator to join our team at Fraser Health. As a key member of our interprofessional team, you will play a vital role in facilitating patients' hospitalization from admission through discharge.

Key Responsibilities
  • Coordinate and collaborate with the interprofessional team to expedite effective, quality patient care and coordinate timely and sustainable discharge plans.
  • Intervene to address barriers and provide leadership as needed to achieve optimal outcomes, including helping to expedite additional services as required.
  • Develop and implement policies, procedures, and standards to support effective care management and discharge planning.
  • Evaluate progress towards desired outcomes to ensure plan of care and services provided are patient-focused, of high quality, efficient, and effective.
  • Coordinate care and discharge planning for patients, proactively collaborating with the Patient Care Coordinator, physician, and interprofessional team to determine discharge goals.
  • Work closely with the Home Health Liaison team to determine available services and prioritize discharge planning activities based on patient level of need/risk.
  • Lead interdisciplinary rounds by facilitating care planning with the healthcare team and other stakeholders.
  • Facilitate patient flow activities by identifying patients requiring specialized attention to move effectively through the system.
  • Coordinate patient transfer to alternate levels of care.
  • Act as a resource/advisor for referral to services relative to diagnoses and post-discharge care.
  • Observe, monitor, and evaluate assigned patient progress, symptoms, and behavioral changes by reviewing patients' daily status, anticipating responses to care, and identifying problems or variances from the expected care plan.
  • Intervene to facilitate resolution of problems and removal of barriers.
  • Reorganize priorities and collaborate with the physician and interprofessional team to revise care plans as required to ensure that the plan of care and services provided are patient-focused, high quality, efficient, and effective.
  • Develop and recommend policies, procedures, and standards to support effective care management and discharge planning.
  • Consult and collaborate with physicians and other healthcare professionals/providers in the identification and resolution of a variety of patient care issues.
  • Identify and resolve potential barriers to efficient care delivery through collaboration with the Manager, Clinical Operations, Patient Care Coordinator, and the interprofessional team.
  • Coordinate and lead case conferences/meetings with patients, family, and service providers for resolution of patient care issues.
  • Act as a patient advocate to protect and promote the patient's right to privacy, dignity, and access to information and to ensure the patient's choice and autonomy in decision making and care planning.
  • Act as a resource to staff, patients, and families regarding care management and discharge planning.
Requirements
  • Current practicing registration as a Registered Nurse with the British Columbia College of Nurses and Midwives (BCCNM).
  • Three years recent, related acute care experience, including one year of experience in community care and discharge planning, or an equivalent combination of education, training, and experience.
  • Comprehensive knowledge of nursing theory and practice within a patient/family-centered model of care.
  • Comprehensive knowledge of the BCCNM Standards of Practice.
  • Broad knowledge of evidence-based nursing practice related to various patient population groups and demonstrated ability to apply knowledge to a case management process.
  • Ability to apply knowledge of pathophysiology and pharmacology to safely plan discharge.
  • Broad knowledge of the illness or disease process and potential long-term complications.
  • Broad knowledge of other healthcare disciplines and their role in patient care.
  • Broad knowledge of clinical pathways, expected length of stays, resource utilization, and patient assessment.
  • Broad knowledge of external agencies and community resources.
  • Ability to engage in comprehensive assessment, observation, and monitoring of patients.
  • Ability to plan, organize, and prioritize work.
  • Ability to analyze situations, problem solve, deal with conflict, and negotiate resolutions in a timely manner.
  • Ability to provide leadership and consultation.
  • Ability to work independently in an organized and self-directed manner and also as a member of an interprofessional team.
  • Ability to communicate effectively both verbally and in writing.
  • Ability to operate related equipment, including applicable software.
  • Physical ability to perform the duties of the position.

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