Jemez Pueblo

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Clinical Care Coordinator R/N

at Jemez Pueblo

Posted: 12/24/2019
Job Reference #: 1375
Keywords: hospital, patient, health

Job Description

  • Job LocationsUS-NM-Jemez Pueblo
    Posted Date5 months ago(8/6/2019 1:00 PM)
    Job ID
    # of Openings
    Health Care
  • Overview

    Responsible for performing a variety of clinical care coordination and nursing duties in an outpatient clinical setting. Responsible for the collection, review, and analysis of chronic disease patient information in accordance with protocol and distribution of data to providers for action; development and implementation of outreach efforts to facilitate patient compliance/access; tracking patient’s ER visits and hospital follow-up care; identifying/ utilizing all appropriate available community resources; interacting, planning and coordinating with case management or disease management staff; and supporting care management and follow-up.



    • Tracks patient laboratory tests until results are available, performs flagging and follow-up on overdue results.
    • Tracks patient imaging tests until results are available, performs flagging and follow-up on overdue results.
    • Performs flagging of all abnormal lab results, bringing them to the attention of the assigned clinician.
    • Performs flagging of all abnormal imaging results, bringing them to the attention of the assigned clinician
    • Responsible for notifying patients/families/caregivers of normal lab and imaging test results.
    • Responsible for notifying patients/families/caregivers of abnormal lab and imaging test results.
    • Performs follow-up on all patient newborn screenings.
    • Uses clinical protocols to determine when imaging and lab tests are necessary.
    • Connects with outside health care facilities to support patient safety throughout care transitions.
    • Receives and shares necessary patient treatment information with outside health care facilities to coordinate comprehensive care.
    • Responsible for tracking patient referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports.
    • Uses clinical protocols to determine when a referral to a specialist is necessary.
    • Monitors the timeliness and quality of the referral response.
    • Documents and co-manages arrangements between primary care provider and specialist’s in the patient’s medical record.
    • Systematically identifies patients with unplanned hospital admission and emergency department visits.
    • Responsible for sharing clinical information with admitting hospitals and emergency departments.
    • Coordinates with families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit.
    • Systematic ability to coordinate with acute care settings after office hours through access to current patient information.
    • Exchanges patient information with the hospital during a patient’s hospitalization.
    • Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities.
    • Collaborates with the patient/family/caregiver to develop/implement a written care plan for complete patients transitioning into/out of teams.
    • Responsible for the electronic exchange of information with external entities, agencies and registries.
    • Assists in initiating patient care plans; providing educational information in conjunction with primary care providers related to treatments, procedures, medications, and continuing care requirements.
    • Responsible for notifying patients of upcoming or overdue screenings
    • Responsible for managing assigned primary care provider patient panels.
    • Assists with data collection and analysis for quality improvement.
    • Serves as back-up to registered nurses as needed.
    • Prepares and maintains medical records and files, including laboratory tests and their results, medications and other treatments administered and actions taken; reviews and updates charts.
    • Prepares a variety of reports, correspondence and other written materials as required.
    • Maintains safe and clean working environment in accordance with Clinic procedures, rules and regulations.
    • Follow HIPAA guidelines, Privacy Act and other applicable confidentiality standards; uphold highest standards of privacy and confidentiality.
    • Contributes to the overall quality of the unit’s service provision by developing and coordinating work teams and by reviewing, recommending and implementing improved policies and procedures.
    • Represents the Pueblo with dignity, integrity, and a spirit of cooperation in all relationships with staff and the public.



    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.

    Education and Experience:

    Associate’s Degree in Nursing; AND four (4) years of experience as a Registered Nurse; OR Associate’s Degree in Nursing; AND (2) years of relevant experience as a clinical care coordinator in a nursing positon and team-based primary care environment.

    Clinical Care Coordinator - Registered Nurse

    Required Knowledge and Skills

    Knowledge of:

    • Theory, principles, practices and methods of providing nursing care and services at the level of a registered nurse.
    • Patient care coordination and chronic disease management and tracking.
    • Techniques of medical assessment and evaluation of various age groups.
    • Applicable laws, codes and regulations.
    • Medical record keeping and the standard format for information on charts and other medical documentation.
    • Safety principles, practices and equipment related to the work.
    • Routine infection control procedures and practices.
    • Proper techniques for documentation of examination and treatment information.
    • Techniques for dealing with a variety of individuals from various socio-economic, ethnic and cultural backgrounds, in person and over the telephone.
    • Computer software utilized by the clinic.

    Skill in:

    • Assessing client medical status and situations and taking or recommending appropriate action.
    • Coordinating health care of patients between multiple health facilities.
    • Organization, follow-up, tracking and trending patient health data.
    • Performing skilled nursing in a clinical setting.
    • Using medical instruments and techniques skillfully and safely.
    • Interpreting, applying and explaining applicable laws, codes and regulations.
    • Preparing accurate, clear and concise medical documentation and records.
    • Compiling and summarizing information and preparing periodic or special reports related to the nursing area and client population.
    • Using tact, discretion and prudence in dealing with customers.
    • Using initiative and independent judgment within established procedural guidelines.
    • Establishing and maintaining effective working relationships with a variety of individuals from various socio-economic, ethnic and cultural backgrounds.


    • Valid New Mexico Registered Nurse license
    • Valid New Mexico Driver’s license



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

    Mobility to work in a typical office and clinical setting; agility and dexterity to use standard office and medical equipment; stamina to sit and stand for extended periods of time; strength and agility to lift and carry up to 20 pounds; vision to read printed materials and a computer screen, and hearing and speech to communicate in over the telephone and in person.

    Work is subject to exposure to bodily fluids and other biohazards.

    Application Instructions

    Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!