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Patient Care Management RN
2 months ago
POSITION SUMMARY:
The RN Care Coordinator is responsible for overseeing personalized, patient-centered nursing care by employing the Nursing Process and adhering to the principles of Primary Nursing in alignment with established departmental and hospital protocols.
This role involves care coordination and management for various patient populations, particularly those identified by MDPCP, aiming to enhance health outcomes, lower healthcare expenses, and improve care coordination.
The RN Care Coordinator accepts referrals for care management and maintains an assigned caseload. Utilizing evidence-based practices, data analytics, and innovative strategies, the RN Care Coordinator implements care management principles while applying critical thinking and leadership skills to address the needs of patients and their families.
Assigned to manage a panel of patients, the RN Care Coordinator collaborates with primary care Interdisciplinary Teams (IDT) to coordinate care, achieve desired health outcomes, enhance self-care capabilities, reduce care costs, and deliver exceptional patient care.
In this capacity, the RN Care Coordinator guides the team in leveraging evidence-based practices, data analytics, and innovative care management strategies, while employing critical thinking and leadership to meet the needs of patients and their families.
Understanding and applying population health management principles, the RN Care Coordinator identifies patients with uncontrolled chronic conditions or rising risk indicators and adjusts patient assignments as necessary.
Working primarily within Practice Groups, the RN Care Coordinator addresses the complexities of chronic disease patients with multiple co-morbidities, high acuity, and intricate needs.
This role requires collaboration with providers within practice groups, nursing staff, various hospital departments, and community resources to facilitate medically appropriate and cost-effective care.
The primary responsibilities of the RN Care Coordinator include but are not limited to:
conducting standardized comprehensive needs assessments, determining available benefits and resources, and developing and implementing a tailored care plan for assigned patients that encompasses performance goals, monitoring, follow-up, and outreach activities.
Patients under the care of the RN Care Coordinator may include:complex individuals whose critical events or diagnoses necessitate extensive resource utilization and who require assistance navigating the healthcare system; transitional care management focused on assessing and coordinating post-hospitalization needs for patients at risk of readmission; and high-risk, high-cost patients who frequently utilize emergency services or experience recurrent hospitalizations.
The care plan is developed based on the outcomes of the comprehensive needs assessment conducted by the RN Care Coordinator through thorough medical record reviews and face-to-face or telephonic interactions with assigned patients and their families when appropriate.
Performance goals are centered on resolving critical events, managing chronic diseases, minimizing avoidable admissions and readmissions, ensuring safe care transitions, and enhancing self-management skills while providing an extraordinary patient experience.
Outreach and health promotion services are also included.Comprehensive assessments with required documentation.
Coordination of referrals and transitions of care between providers or care settings.
Medication reconciliation and adherence.
Facilitating timely access to necessary appointments and services for patients.
Patient and Family/Caregiver education.
Evaluation of care plan effectiveness with the IDT Essential Job Functions.
QUALIFICATIONS:
Advanced professional knowledge; Graduate of an Accredited School of Nursing; Bachelor's Degree required, Master's Degree preferred.
Current/Valid Registered Nurse License in the State of Maryland (or Compact State as applicable). Certification in Case/Care management or familiarity with national care management standards and community resources is advantageous. 3-5 years of demonstrated expertise in acute care nursing, knowledge, and skills.
Experience in care management from an acute care setting or health insurance and other payer entities is preferred.Excellent verbal and communication skills, along with strong organizational abilities, are essential.
Proficient analytical, data management, and computer skills. Familiarity with electronic medical records is desirable.
Previous experience in ambulatory and population health is beneficial.
