RN Care Coordinator

Job Summary:

Under the direct supervision of the Manager, RN Care Coordinators, the RN Care Coordinator is responsible for coordinating care for patients of the primary care practice to promote effective education, self-management support, and timely health care delivery. This will include developing and monitoring care management processes and support primary clinical team efforts. It will also include identifying the high risk patient population and working to ensure care coordination for this patient population._x000D_

  • Work with all clinical teams as a resource on care coordination of all patients of the practice.
  • Manages patient care in the health care continuum to achieve optimum outcomes in a safe and cost-effective manner.
  • Demonstrates performance consistent with professional standards of practice, care, and the Nurse Practice Act.
  • Provides optimal care coordination with hospital, ER, consulting physicians, extended care facilities community resources as necessary. Conducts/oversees pre-visit planning to facilitate efficient and effective office visits.
  • Develops workflows to ensure smooth transition of care management to primary care for patients treated in a facility (inpatient or emergency department), by a specialty physician, or by another health care provider.
  • Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Involves patients in developing care plans to improve their health, educates patient about self- management tasks to gain control over health.
  • Provides support for provider leadership of the patient care teams.
  • Collaborates with providers and practice staff in identifying appropriate patients for chronic care management. (CCM) actively manages the panel of chronic care patients.
  • Develop relationship with patient as an integral member of team.
  • Provide follow-up contact with patients as indicated to ensure compliance with recommendations
  • medications, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.
  • Responsible for being available to provide telephone advice per protocol, handle urgent and emergent calls.
  • Completes and tracks appropriate referrals to specialists, community resources and social services.
  • Collaborates with the patient, provider, and other care team members in assessing the patients progress toward individual health care goals; assess barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments.
  • Oversees the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams.
  • Utilize the Institute for Healthcare Improvement (IHIs) Chronic Care Model as foundation and framework for chronic illness care management.
  • Participates in regular team meetings and assigned activities. Participates in departmental and organizational committees as applicable.
  • Collaborates with practice quality facilitators to manage and identify opportunities within the patient/ chronic disease registry.
  • Collaborate with payer Case Managers for additional services when appropriate.
  • Develops a list of medical supply and community resources available to patients and maintains collegial relationships with the entities used most frequently.
  • Utilizes population heath tools and databases, electronic patient registries, and other reports as available to collaborate with providers and quality facilitators to identify, manage, address care and utilization opportunities within high-risk patient, ACO(Accountable Care Organization) and chronic disease registries.
  • Follows system and department policies and procedures with special attention to attendance, punctuality, confidentiality, dress code and display of ID badge, and safety.
  • Completes mandatory education and training in order to maintain organization and department specific competencies and requirements. Maintains applicable certification/licensure. Maintains current Basic Life Support (BLS).
  • Other duties as assigned
  • Graduate from an accredited school of nursing.
  • valid state license to practice as a Registered Nurse in the State of Ohio. Maintains current Basic Life Support (BLS).
Complexity of Work:
  • Maintains competencies specific to patient population served.
  • Knowledge of the principles and skills needed for practical nursing to provide patient care and treatment.
  • Knowledge of examination, diagnostic, and treatment room procedures.
  • Analytical skills in creating and maintaining records, and writing reports using excel and other similar software packages.
  • Knowledge of medical practice and care of patients.
  • Knowledge of medical equipment and instruments.
  • Skill in developing and maintaining clinical quality assurance.
  • Ability to define appropriate policies and workflow procedures for the coordination of care with emphasis on strong communication skills.
  • Ability to use good judgment and critical thinking skills; ability to identify and resolve problems.
  • Ability to interpret, adapt, and apply guidelines and protocols.
  • Ability to maintain electronic medical records.
  • Ability to establish and maintain effective working relationships with patients, families, medical staff, and co-workers.
  • Ability to work independently, while collaborating with other team members.
  • Ability to self-motivate, prioritizes, and be willing to invest in a change process to improve Efficiencies.
  • Excellent written, verbal and listening communications skills Ability to work with a diverse patient/family population.
Work Experience:
  • Three years of physician practice experience.
  • Knowledge of common safety hazards.
Physical Requirements:

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