The RN Program Coordinator is the primary point person for ensuring the collaborative care of patients from the time of hospital discharge through all follow ups. They work closely with hospital and other PPG staff to ensure smooth transition of care including testing and clinic visits.

ACCOUNTABILITIES

Overall coordination of provider clinic:

Facilitate patient plan of care, as outlined by provider during office visit. Review the patient’s Health Risk Assessment to identify potential barriers, risk factors, opportunities for education and gaps in recommended preventive services. Provides education and instructions for procedures and/or testing order by providers. Coordinate patient’s procedures and/or possible hospital admissions—requiring coordination with both inpatient and outpatient services. Participate in patient’s clinical appointments, assisting in care of patient. Review and complete FMLA & disability paperwork for patient and patient caregivers. Prepares the patient for the visit by gathering base line data from the patient, documenting reasons for the visit and obtaining vitals/office testing. Performs specific specialized tests (i.e., pulmonary function tests, phlebotomy procedures) as needed.  Anticipates and prepares the patient, clinical equipment and supplies for the visit. Assists and/or performs procedures alongside physician.

Triaging patient calls:

Gather and review eligible patient’s self-reported health information. Triage symptomatic patient phone calls; coordinate care for patient with provider and/or other service lines/specialties. Furnish personalized health advice to the patient and provide referrals as appropriate for recommended testing or preventive counseling. Engage patient in self-management. Review the patient’s Health Risk Assessment to identify potential barriers, risk factors, opportunities for education and gaps in recommended preventive services. Monitor patient’s chart for test results. Triage results and review for abnormalities with ordering provider. Communicate test results to patient in a timely manner and facilities any further orders outlined by provider. Review and manage preoperative surgical clearance request with providers, if needed. This would include communicating surgical risk stratification to both surgical team & patient. Must also communicate any further orders specific to surgery—example: medications that must be held prior, bridging of medications before and after surgery and/or any testing needed prior. Communicates effectively with patients, peers, and all members of the health care team. Listens and responds to verbal and non-verbal communication of patients, families, and staff members. Relates to patients in caring manner. Relates complete and pertinent information in verbal and written form appropriate to the ages of patient served. Demonstrates understanding of legal implications of charting, documents clearly and objectively all encounters with patients. Review and manage per Triage phone calls; Coordinate care for patient with provider and other service lines/specialties. Furnish personalized health advice to the patient and provide referrals as appropriate for recommended testing or preventive counseling. Coordinate patient’s procedures and possible hospital admissions. Participate in patient’s clinical appointments, assisting in care of patient. Review and queue patient’s medications for provider to review and sign. Ensure proper protocols are followed when refilling medications. Additional responsibilities/duties will be assigned based on teamwork load and competency