Clinical Care Coordinator

6 days ago

Philadelphia, Pennsylvania, United States Oak Street Health Inc Full time

At Oak Street Health, we are on a mission to revolutionize healthcare by providing high-quality, patient-centered care to adults on Medicare. As a Clinical Care Coordinator, you will play a crucial role in facilitating safe and timely discharge, appropriate follow-up care, and next steps for our patients.

About the Role

We are seeking an experienced RN with a passion for transitional care to join our team. The ideal candidate will have a minimum of 2 years of experience in transitional nursing, emergency room nursing, discharge planning, or home health, as well as a strong understanding of Medicare/Medicaid and NCQA regulatory transitions of care criteria.

Key Responsibilities
  • Transitions Management:
    • Manage patients through transitions of care, either face-to-face in the facility or telephonically, within a defined geographical area and care setting.
    • Advocate for the patient throughout the care continuum to ensure access to resources and resolution to all barriers to care.
    • Identify opportunities for improved program workflows, increased internal and external partnerships, and higher quality patient care.
  • Collaboration and Communication with Internal Stakeholders:
    • Collaborate with other transitions team members (e.g., Transitional Care Managers - Social Work and Transitional Care Coordinators) to ensure safe discharge and timely follow-up.
    • Communicate and coordinate with internal stakeholders to identify and address patient needs (e.g., care team, social work, behavioral health, utilization management, Hard-to-Reach, Central Telehealth, etc.).
  • Collaboration and Communication with External Stakeholders:
    • Participate in regular meetings with the Program Director and other Transitional Care Managers on programmatic development and clinical learning.
    • Identify partnership development opportunities and systems improvements.
  • Documentation, Tracking, Reporting, and Training:
    • Participate in initial and ongoing required training to ensure appropriate implementation of transitions activities and programming.
    • Follow program procedures for documenting and tracking transitions interventions.
What We're Looking For
  • An active RN license within the state of practice in good standing
  • A willingness to obtain cross-state licensure, as needed
  • Nurse Case Management Credentialing (RN-BC) or Certified Case Manager (CCM) required, or willingness to obtain within 12 months of hire
  • A minimum of 2 years of experience in transitional nursing, emergency room nursing, discharge planning, or home health
  • Experience in utilization management preferred
  • Knowledge of Medicare/Medicaid and NCQA regulatory transitions of care criteria
  • Exceptional communication skills and customer service orientation
  • Innovative and independent problem-solving skills
  • An ability to monitor and evaluate opportunities for cost-effective care options with high-quality outcomes
  • A flexible, positive attitude
  • Access to reliable transportation and ability to travel daily
  • A working knowledge of Microsoft Office Product Suite
  • US work authorization
Salary and Benefits

We offer a competitive salary of $85,000 per year, paid vacation and sick time, a generous 401(k) match with immediate vesting, and comprehensive health benefits. If you embody the values of being 'Oaky', which includes radiating positive energy, assuming good intentions, creating an unmatched patient experience, driving clinical excellence, taking ownership, and delivering results, we encourage you to apply for this exciting opportunity

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