Care Coordinator RN

13 hours ago

Canton, New York, United States Rochester Regional Health Full time
Care Coordinator RN Job Description

At Rochester Regional Health, we are dedicated to delivering exceptional healthcare services to our community. As a Care Coordinator RN, you will play a vital role in ensuring that our patients receive the highest quality care.

Key Responsibilities:
  • Systematically identify individual patients and plan, manage, and coordinate their care based on condition, needs, and evidence-based guidelines.
  • Provide assessment, care planning, and coordination, and advocacy to patients and their families.
  • Develop, formulate, implement, and revise self-management care plans with a shared-goal model, incorporating patient-specific education as appropriate.
  • Evaluate patient responses to interventions, identifying and developing strategies to barriers in achieving positive clinical outcomes.
  • Coordinate care with community and regional ancillary health services for extended needs of patients and ensure that patient-specific care plans are developed and documented by the practice clinical team.
  • Educate patients and families regarding relevant wellness issues, disease process, and treatment plan, if not bringing to the attention of the physician.
  • Serve as the contact point, advocate, and informational resource for patients, care team, family/caregivers, payers, and community resources.
  • Promote timely access to appropriate care, increase utilization of preventative care, reduce emergency room utilization and hospital readmissions, and increase comprehension through culturally and linguistically appropriate education.
  • Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregivers.
  • Manage referrals, when needed, to appropriate agencies required to assist the patient in achieving the goals and objectives defined in their Care Plan.
  • Define and direct patients and/or families to appropriate resource utilization, increase patients' ability for self-management and shared decision-making, connect patients to relevant community resources, and assist patients in problem-solving potential issues related to the healthcare system, financial or social barriers.
  • Assist with data collection and generation of patient registry reports, attend and participate in team/educational conferences as needed.


Requirements:
  • Completion of an accredited Registered Nurse training program.
  • Current, unrestricted New York State registered professional nursing license.
  • Certification through the American Academy of Ambulatory Care Nursing in Care Coordination and Care Transitions required within 18 months of employment.
  • Chronic Disease Self-Management Certification required within 12 months of employment.


Preferred Qualifications:
  • Willingness to obtain ongoing and up to date population-specific education.
  • 3-5 years' experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.
  • Experience with Patient-Centered-Medical Home desirable.


About Rochester Regional Health:
Rochester Regional Health is an Equal Opportunity/Affirmative Action Employer. Minority/Female/Disability/Veterans by a prospective employee and/or employee's Physician or delegate will be considered for accommodations.

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