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Nurse Care Coordinator RN
2 months ago
Bon Secours Mercy Health is seeking a highly skilled and compassionate Registered Nurse to join our team as an Ambulatory Care Manager. In this critical role, you will provide clinical care management services to identified eligible patients, coordinating care to achieve desired health outcomes, improve self-care abilities, and reduce unnecessary costs.
Key Responsibilities- Utilize Motivational Interviewing techniques to activate patients in self-management of their chronic conditions, aiming to improve symptom management and interrupt negative disease trajectories.
- Maintain a caseload of patients according to department policies, ensuring timely and effective care.
- Identify, enroll, and manage patients in programs for Transitions of Care, Complex Case Management, and Chronic Disease Management.
- Develop and implement care plans to maximize healthcare outcomes and facilitate wellness, with periodic review and update according to department protocols.
- Perform medication review and teach-back to ensure patient understanding and adherence to medical regimens.
- Collaborate with Primary Care Physicians, Specialists, and Hospitalists to effectively implement patient-centered care plans.
- Perform patient outreach according to established protocols and document in electronic medical records.
- Identify, execute, and track needed referrals to care and community resources.
- Provide resource management to improve care, patient experience, and reduce unnecessary costs and utilization.
- Assist patients in advanced care planning to complete Advanced Directives.
- Document all communications with patients and/or care teams in electronic medical records.
- Demonstrate knowledge and skills necessary to provide care appropriate to the age of patients served on assigned units.
- Demonstrate knowledge of principles of growth and development of the life span and possess ability to assess data reflective of patient's status and interpret appropriate information needed to identify each patient's requirements relative to their age, specific needs, and to provide care needed as described in departmental policies and procedures.
- Required Minimum Education: Associate's Degree in Nursing.
- Preferred Education: Bachelor's Degree in Nursing (BSN).
- Licensure/Certification Required: Registered Nurse with active License in State of Patient Care.
- Licensure/Certification Preferred: Case Management certification.
- Minimum Qualifications: 2-3 years acute care, home health, or case management experience.
