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Care Coordination Nurse

2 months ago

Bedford, United States HYNDMAN AREA HEALTH CENTER, INC. Full time

Benefits:

401(k) matching

Dental insurance

Health insurance

Paid time off

Training & development

Vision insurance

Summary:

The Care Coordination nurse is responsible for supporting and coordinating the physical health care of patients on an assigned patient caseload with the patient’s medical provider, and when appropriate, other specialists.

Duties/Responsibilities:

· Engage patients, inform them of their needs, and empower them and their families to achieve understanding of their chronic disease management process.

· Screen patients for medication adherence, social determinants of health, and physical needs. Facilitate patient engagement and follow–up care.

· Provide patient education about chronic disease management, as well as available financial, social, and community resources.

· Monitor and take responsibility for a patient population as well as track on up to date preventative measures.

· Systematically track treatment response and monitor patients (by telephone) for changes in medication adherence, and physical health.

· Provide resources when appropriate.

· Collaborate with provider to assist in initialing an individual care plan with goals for patient.

· Track patient follow up and clinical outcomes using a care plan. Document telephone encounters in the care plan and use the system to identify and re-engage patients. Functions can be accomplished through ECW, or on a spreadsheet use in conjunction with ECW.

· Document patient progress and recommendations in ECW and other required systems so as to be shared with medical providers, caregivers, and other treating specialists.

· Facilitate collaboration with payer and medical provider to initiate available resources for patients.

· Discuss end of life care, including advance directives, DNR/DNI, and power of attorney.

· Attend and actively participate in care management related trainings and meeting activities.

· Be the lead in the development of Chronic Disease model of care for the organization

· Collaborates with the Chief Medical Officer and other appropriate parties in working toward and obtaining PCMH certification.

Qualifications:

· Must be a graduate for an accredited school of nursing, LPN, or CMA

· License to practice in the State of Pennsylvania

· CPR/AED Certification

· Knowledge & skills for the provision of patient care in the practice of primary health care that is age and culturally appropriate.

· Knowledge of the principles or growth and development of all life spans.

· Skill in communicating effectively with patients and their families; interpreting patient data for care requirements after medical assessment.

· Skill in establishing and maintaining effective working relationships with other employees, patients and the general public.