JOB SUMMARY: The primary function of this position is to act as an on-site health and wellness coach for patients who need coaching around health issues like diabetes management, weight management, hypertension, etc. The Coordinator will conduct group classes on health and wellness topics like diabetes management, weight management, etc.
Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc. Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence
The responsibilities listed are a general overview of the position and additional duties may be assigned.
RN ACCESS PATIENT EDUCATION (ADVANCED): - Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums.
NURSING PATIENT ASSESSMENT & EVALUATION (ADVANCED): - Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers.
EVIDENCE-BASED PRACTICE (ADVANCED): - Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.
TREND ANALYSIS (INTERMEDIATE): - Demonstrates mastery of trend analyses. Can recognize the impact and take into consideration the effect of seasonality and randomness. Has analyzed trends in detecting patterns that could lead to future problems and in forecasting future demand periods. Has worked in several areas that might include sales, marketing, quality, finance and manufacturing.
Internal Number: 1904071
About Vanderbilt Health
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period.Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As th...e largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.