Nurse Care Coordinator

4 weeks ago


Quincy, Massachusetts, United States SIU Medicine Full time
Job Summary

This position serves as a key member of the hospital team, working in collaboration with primary care physicians and patients to provide a transition of care model that is conducive to the delivery of quality, efficient, and cost-effective healthcare services. The primary focus is on transitions from the hospital to home and long-term care facilities.

Key Responsibilities

1. Works under the direction of the hospital team providing nursing support to assist with and bridge gaps between the inpatient and outpatient settings.
2. Serves as an extension of the hospital team, establishing rapport with the patient and/or caregiver to ensure hospital discharge appointments are made and the importance of the visit is communicated.
3. Provides patient education in anticipation of discharge and assists residents and attending providers with discharge documentation.
4. Attends in-patient rounds to gain understanding of and participate in the patient's care and treatment. Assists the team in proactively identifying care needs or linking with applicable services to facilitate transition home or to another facility.
5. With the healthcare team, identifies patients at higher risk for readmission and assures coordinated efforts are made to break down barriers and implements a patient-centered, nursing plan of care that promotes health improvements.
6. Provides telephone triage for all incoming calls from patients, pharmacies, and other healthcare agencies regarding care of discharged patients.
7. Places follow-up calls to patients within 2 days of discharge to confirm status, reconcile meds, identify any immediate concerns, and problem-solve any treatment gaps identified.
8. Conducts additional follow-up calls as needed during the initial post-discharge phase to support patient goals, reassess patient progress, and barriers toward goals. Provides further patient education as identified.
9. Communicates with the hospital team and/or PCP to ensure patient follow-up.
10. Assists in reconciling med lists between the hospital discharge summary and the clinic EHR at the direction of the hospital attending.
11. Maintains accurate, up-to-date documentation for all case management activities.

Qualifications

1. Possession of a valid license as a Licensed Practical Nurse issued by the Illinois Department of Financial and Professional Regulation, Division of Professional Regulation.
2. Six months of nursing experience in a healthcare facility (such as a hospital, nursing home, medical clinic, prison, mental health facility, or closely related facilities).

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