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RN Care Coordinator

2 months ago

Cincinnati, Ohio, United States The Christ Hospital Full time

Job Overview

The primary responsibilities of this role include ensuring continuity of care throughout the healthcare system. This position serves as a guide and advocate for improved health outcomes for patients under the care of the primary healthcare provider. The Care Coordinator is tasked with overseeing high-risk patients who have multiple health conditions or are at significant risk for hospital admissions or readmissions. This encompasses the creation and monitoring of health promotion strategies, disease management plans, care coordination, and resource utilization management. The Care Coordinator will collaborate with the care team to formulate care plans that facilitate the patient's journey towards optimal health. Additionally, this role will ensure smooth transitions of care following hospital admissions, providing patients with a seamless experience and well-organized care.

Key Responsibilities

Care Coordination - Collaborate with all clinical teams as a resource for care coordination


• Identify specific patient groups that would benefit from enhanced care coordination.


• Implement pre-visit planning processes to ensure care tasks are completed prior to patient visits whenever feasible.


• Utilize efficient and precise point-of-care reminders to support evidence-based care.


• Coordinate patient care services for selected individuals across the healthcare continuum through collaboration with patients, families, and healthcare providers to achieve optimal outcomes.


• Communicate with patients post-hospitalization to arrange follow-up appointments, assist with medication education, review after-visit summaries, and provide a reliable point of contact.


• Work closely with the Care Team to ensure smooth transitions of care for patients treated in various settings, including inpatient facilities or emergency departments.


• Engage patients in activities that promote their health (patient engagement);


• Educate patients on self-management strategies to empower them in controlling their health.


• Provide health education and counseling to patients and their families.


• Identify obstacles that hinder patients from achieving optimal health, collaborate with the Care Team and external resources to devise solutions.

Clinical Quality and Performance


• Collaborate closely with providers and clinical staff to ensure clinical quality remains a priority throughout all patient care phases.


• Participate in clinical quality initiatives and facilitate the adoption of best practices.


• Network and collaborate with professional peers and community agencies to develop and implement best practices.


• Coordinate with physician leadership to devise strategies for managing high-risk patient populations, ensuring seamless care transitions from office to hospital to home.


• Monitor resource utilization and work with patients and the care team to promote efficient and appropriate use of services.


• Provide leadership in developing office workflows, collaborating with physicians to establish care standards for preventive services and chronic disease management.


• Lead the healthcare team by exemplifying and modeling effective nursing practices, outstanding customer service, innovation, and exceptional support for the physician practice.


• Ensure adherence to safe practices and report any concerns.

Commitment to Customer Service


• Deliver the highest level of customer service to achieve the goal of prioritizing patient needs.


• Promote excellence in healthcare delivery to patients and their families. Identify and facilitate the implementation of clinical best practices.


• Engage colleagues and patients in a positive and respectful manner.


• Show respect and sensitivity to the diverse backgrounds of colleagues and patients.


• Ensure a seamless patient experience by coordinating care with the care team, patients, and their families.

Information Technology:


• Ensure complete and accurate documentation in the medical records.


• Effectively utilize all electronic tools to deliver evidence-based care.


• Design effective workflows using population management software, electronic medical records, and registries.


• Collect and monitor data related to patient outcomes.


• Participate in performance improvement initiatives to leverage electronic medical records.

Additional Duties

Qualifications

KNOWLEDGE AND SKILLS:

Please outline any specialized knowledge or skills required to perform the duties of this position. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.

EDUCATION: Registered Nurse

EXPERIENCE: Minimum of 3 years of experience in a relevant field.

REQUIRED SKILLS AND KNOWLEDGE:

• Autonomous work style

• Strong problem-solving and critical thinking abilities

• Capacity to prioritize tasks and manage multiple demands

• Proficient in basic computer functions

• Effective communication skills, both written and verbal

• Ability to collaborate effectively within a team

• Respect and sensitivity towards cultural differences among colleagues and patients

• Knowledge and alignment with the organization's goals and values

LICENSES & CERTIFICATIONS:

Must possess a current Registered Nurse license in the state of Ohio.