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Canton-Potsdam Hospital Care Coordinator in Potsdam, New York

The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach. Facilitates “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered that address. Acts as a liaison between patients and the healthcare system. Ensures that patients receive the care they need and that they understand their medical condition, medications, and other instructions. Coordination of patient-care services to help reduce costs by reducing duplication of services.

Care Coordination:

  • Systematically identifies individual patients and plans, manages and coordinates their care, based on condition, needs and on evidence-based guidelines based on quality goals of organizations and population needs.

  • Provides assessment, care planning and coordination, and advocacy to patients and their families.

  • After assessing the health status of patients, develops, formulates, implements, and revises self-management care plans with a shared-goal model, incorporating patient specific education as appropriate for high risk patients and others, as defined by the practice.

  • Evaluation of patient responses to interventions, identifying and developing strategies to barriers in achieving positive clinical outcomes.

  • Coordinates care with community and regional ancillary health services for extended needs of patients and ensures that patient specific care plans are developed and documented by the practice clinical team.

  • Educates patient/family regarding relevant wellness issues, disease process, and treatment plan, if not bringing to the attention of the physician.

  • Educates patients with appropriate method suitable for individual learning abilities regarding diet, medication, or test needs, if not bringing to the attention of the physician.

  • Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.

  • Promote timely access to appropriate care.

  • Increase utilization of preventative care.

  • Reduce emergency room utilization and hospital readmissions.

  • Increase comprehension through culturally and linguistically appropriate education.

  • Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).

  • Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.

  • Tracks and reports on patient progress.

  • Manage referrals, when needed, to appropriate agencies required to assist the patient in achieving the goals and objectives defined in their Care Plan.

  • Defines and directs patients and/or families to appropriate resource utilization.

  • Increase patients’ ability for self-management and shared decision-making.

  • Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, reduce social barriers to care, and decrease health care costs.

  • Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g. request interpreters as appropriate, transportation services, or prescription assistance.)

  • Assist with data collection and generation of patient registry reports.

  • Attends and participates in team/educational conferences as needed.

Care Delivery:

  • Maintains safe and effective nursing care rendered directly or indirectly, adjusting nursing care processes as necessary to ensure optimal patient care.

  • Triage patient phone calls.

  • Provide medication reconciliation.

  • Pre-Visit planning prior to physicals of patients identified in registry.

  • Performs RN-Led Annual Wellness Visits

  • Make adjustments in patients' medications following physician directed guidelines to achieve therapeutic levels.

  • Evaluates patient response to those interventions.

  • Placing orders for lab tests, immunizations or ancillary testing per protocol, under provider guidance.

  • Assist & manage follow-up care as requested by Primary Care physician.

  • Leads patient care team in daily and/or weekly huddle discussions to prepare for the day or week ahead.

  • Works closely with community resources to coordinate care needed by high risk patients, as defined by the practice.

  • Under direction of practitioners, communicate test results and care plans to patients/families.

  • Assists and completes various forms for the patient.

  • Responsible for coordinating and leading patient support groups and/or shared medical appointments.

Quality & Regulatory:

  • Participates in Performance Improvement/Continuous Quality Improvement activities, as assigned.

  • Works with PPM management team to comply with all established standards and regulations per DNV standards and hospital compliance requirements.

  • Works with PPM management team to resolve clinical issues (processes, performance, etc.) to identify opportunities for improvement.

  • Adheres to CPH and PPM policies and procedures, protocols, guidelines, etc.


  • Serve as a mentor and a resource provider for clinic and hospital staff.

  • Provide education to patients and significant others, as well as staff.

  • Maintains a level of communication that exceeds the person’s expectations in every encounter.


ID: 2021-7650

Shift: 7.5 Hour

Shift Details: 7.5HR: Variable Shifts

External Company URL: https://www.stlawrencehealthsystem.org/

Name: Physician Practice Management

Required Level: Associate's Degree

Required Field: Completion of an accredited Registered Nurse training program.

Preferred Level: Bachelor's Degree

Preferred Field: Bachelor’s of Science of Nursing

Licensure / Certification (Text Only): Required: Licensed in good standing as a Registered Nurse under the State of New York licensing criteria. Current AHA BLS certification required.

Preferred: Current AHA ACLS

Contract: SALARY

Post: St. Lawrence Health System Careers: 5/28/2021