RN Care Coordinator

4 months ago

Texas City, United States Galveston County Health District Full time

Coastal Health & Wellness is seeking an RN Care Coordinator

The RN Care Coordinator position is responsible for managing high risk, chronic illness patients to promote effective education, self-management support, and timely access to healthcare to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality cost-effective outcomes.

Acts as an advocate for the individual's healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems. Serves as a liaison between the patient, family, and health care team. This position is committed to the constant pursuit of excellence in improving the health status of all CHW patients and the community.

We can offer you:

  • Excellent Benefits; including an Amazing retirement package, Paid Time Off plans, Affordable Medical Insurance, FREE Life Insurance, FREE Long-Term Disability, FREE Parking and much more
  • Team Oriented Environment
  • Salary Rate: Based on experience
We want you to join our team of professionals and begin a long-term career with us If you meet the criteria listed below, please apply.

Required:
  • Bachelor's in nursing required.
  • Licensed to practice as a Registered Nurse in the State of Texas.
  • Must have strong case management experience, 2 years minimum.
  • Preferred in experience with CMS Chronic Care Mgt and Transitional care management.
  • Clinical knowledge base of chronic conditions such as diabetes and heart disease.
  • Demonstrated ability to assess and respond to patient and family needs in a timely manner.
  • Strong attention to detail.
  • Excellent communication skills to effectively coordinate care between patient and medical teams.
  • High emotional intelligence to create a positive patient care experience that includes simplifying medical terminology and concepts to the patient.
  • Customer Service Oriented.
  • Strong problem-solving and conflict resolution skills.
  • Computer Skills in MS Office and electronic health record software.
  • Ability for spur of the moment transportation without relying on organization vehicles.
  • Must be willing and able to work evening and weekend hours if necessary.
  • Must be in compliance with GCHD Immunizations policy.
  • Must be in compliance with ICS training requirements.
An equivalent combination of education and work experience which appropriately demonstrates the knowledge, skills and abilities to perform the above-described essential functions will be considered when hiring for this role.

Traditional Duties:
  • Collaborates with medical, counseling, substance use disorder, and dental providers and practice staff in identifying appropriate patients for care management using established Care Management criteria.
  • Performs initial and periodic holistic assessments for care-managed population. This includes physical and psychological assessments as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the patient. Prioritize patients according to intensity, need, and required follow-up.
  • Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family issues, resources, and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
  • Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients are action-oriented.
  • Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues, and goals. Monitors and evaluates the progress of the patient.
  • Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
  • Identifies and effectively utilizes community resources to meet the needs of patients/families.
  • Facilitates patient access to community resources as appropriate or refers to other resources inside CHW.
  • Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
  • Performs follow up calls for patients recently discharged from acute hospitalizations, ED admissions, and those who are considered high-risk for readmission. Ensures that the patient has an accurate understanding of the reason for admission and the importance of follow-up care at CHW post admission.
  • Maintains a NexGen database on care managed population. Maintains accurate and timely documentation in NexGen by utilizing Care Management Templates.
  • Reviews quality and utilization reports routinely and scans for "gaps in care" to identify patients needing additional care management support. Routinely addresses preventive screenings via the NexGen Health Maintenance report and Care Guidelines.
  • Reviews patient records prior to contacting patients to ensure that care is as comprehensive as possible. Performs medication reconciliation for all care transitions.
  • Respond to public health emergencies as needed on weekends or evenings and other activities under the organization's Strategic Health Plan Coordinates with other departments and/or community partners as needed Carry out the mission, vision, and values of the organization.
  • Performs other duties as assigned by supervisor.


No Phone Calls Please

ADA/EEO/DFWP

Our Mission: Protecting and Promoting the One Health of Galveston County

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