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Job Summary:The RN Care Coordinator facilitates the clinical management and promotes continuity of care for an assigned population with complex care needs by partnering with assigned providers, patients and caregivers. Complex care includes, but is not limited to: high risk score, high service utilization, need for transition across continuum points, gaps in care and/or referral by providers. Utilizes clinical knowledge in the application of care coordination principles to help patients achieve self-management goals and assists in the development of an individualized plan of care. The RN Care Coordinator uses motivational interviewing to identify goals and barriers, and promotes cost-effective utilization of healthcare resources while collaborating with members of the healthcare team; which includes patient and family, providers, clinical staff, community agencies and health plan.
Essential Functions and Responsibilities:
- Applies data driven methods for identifying and screening high risk patients for disease management and care coordination.
- Conducts comprehensive assessment of healthcare, educational and psychosocial needs of patients and their families/caregivers. Provides support, education and assistance in the prevention and/or maintenance of disease and/or health and wellness state for patients with chronic and acute care needs
- Coaches patients and caregivers in self-management. Evaluates patient's progress toward goals, reinforces appropriate behaviors to positively influence and increase patient's compliance with treatment plans
- Enlists a team approach by working collaboratively with the family, primary care provider and other members of the healthcare team to ensure coordination of services at multiple provider sites and establishes a plan of care to meet the patient's individual needs. Promotes communication and collaborative coordination of care.
- Provides telephonic and/or face to face follow up with patients for care coordination services; conducts appropriate tracking (daily, weekly, monthly) of caseload, as assigned.
- Coordinates discharge planning needs with facilities and health service providers to support smooth transitions in care.
- Provides post-discharge support and coordinates transitional and community-based care.
- Consults with leadership regarding care that does not appear to meet evidence-based medicine and/or medical necessity.
- Links patients and their family to other members of the care team to help patients gain knowledge of their disease process.
- Provides support for patients experiencing a medical or behavioral health need and refers patients to appropriate clinical providers for assessment and treatment as clinically indicated.
- Facilitates access to community services. Engages community resources to support the patient's optimal functioning.
- Supports and facilitates care coordination activities within physician practices.
- Documents all contacts in the care coordination documentation system.
- Performs other duties as assigned.
Qualifications:
- Valid RN License from Virginia or reciprocal compact state required.
- Graduate of an accredited nursing program,Bachelor's degree in Nursing (BSN)preferred.
- Minimum of five years clinical experience in acute care or ambulatory care setting required.
- Experience with electronic medical records and computer proficiency with applications such as MS Word, Excel and Access required.
- Experience in case management (or CCM certification), discharge planning, home care and/or utilization management preferred.
As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.