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Patient Care Coordinator RN
2 months ago
Oversees specific patient demographics to ensure effective and efficient healthcare delivery. This role encompasses the coordination, facilitation, monitoring, and assessment of interventions aimed at achieving optimal health outcomes.
Works collaboratively with the Primary Care Physician (PCP) and is an integral member of a multidisciplinary team, guiding high-risk patients through various healthcare environments, including inpatient, outpatient, and post-acute care.
Ensures seamless care continuity through established, evidence-based practices, which include, but are not limited to, medication management, self-care planning, family and caregiver engagement, health education, and referrals.
Collaborates with fellow care team members to identify and address care gaps. Strives to enhance clinical outcomes and patient satisfaction while promoting efficient resource utilization.Key Responsibilities:
Facilitation of Patient-Centered Care:
- Identifies, assesses, engages, and enrolls high-risk patients from designated populations.
- Conducts comprehensive evaluations of patients' current health conditions, identifying barriers to optimal health and available resources.
- Collaborates with patients, families, caregivers, and healthcare team members to create an initial Care Plan and Self-Management Plan that target opportunities for improving clinical outcomes and reducing care gaps.
- Oversees and monitors the execution of the Care Plan.
- Coordinates patient, family, and caregiver involvement in the Care Plan and self-management strategies.
- Leverages knowledge of community resources to support goal achievement.
- Facilitates patient education aligned with the Care Plan using evidence-based techniques such as teach-back.
- Conducts home visits as needed to assess barriers to self-management goals and formulates strategies to overcome these challenges.
- Performs additional duties as assigned.
Interdisciplinary Collaboration:
- Participates in the development and implementation of the Care Plan across the continuum of care, including acute, post-acute, and home settings.
- Demonstrates expertise in case management and serves as a resource for the interdisciplinary healthcare team.
- Integrates knowledge of regulatory requirements into case management practices.
- Collaborates with inpatient and outpatient healthcare staff, as well as community resources, to ensure continuity of care.
- Acts as a consistent point of contact for patients across clinical settings.
- Facilitates referrals to other disciplines and programs to enhance patient outcomes.
Evidence-Based Care:
- Utilizes knowledge of efficiency and effectiveness metrics (e.g., Process Metrics, NCQA, URAC, HEDIS) in coordinating and facilitating the Care Plan.
- Continuously enhances knowledge of best practices and clinical standards, integrating this knowledge into daily practice.
Documentation and Reporting:
- Accurately documents in the medical record and designated case management tools, reflecting collaborative care planning, interventions, and evaluations against established targets and goals.
Additional Responsibilities:
- Capable of performing any clinical or administrative tasks as required.
- Adheres to all OSHA and HIPAA regulations.
- Exhibits strong verbal and communication skills.
- Manages stressful situations with professionalism.
- Available to work flexible hours as necessary.
- Understands and implements company policies and procedures.
- Provides exceptional customer service, demonstrating awareness and sensitivity to the needs of clients.
- Takes personal responsibility for professional development, including acquiring new skills and knowledge.
- Engages in effective communication, including active listening and professional speaking.
- Participates in projects and other responsibilities as assigned by leadership.
- Demonstrates attention to detail and accuracy in all work products.
- Sets and achieves challenging goals.
- Performs other duties as assigned.
Qualifications:
- Bachelor's degree or professional certification/license with 2-4 years of experience, preferably including 2 years in case management.
Licensure:
- Registered Nurse (RN) with an active license in the state of Ohio; BSN required.
