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Care Coordinator RN
2 months ago
**Job Summary:**
We are seeking a highly skilled and compassionate Care Coordinator RN to join our team at Carle Health. As a key member of our population health management team, you will play a vital role in providing care management and coordination services to patients across the continuum.
Key Responsibilities- Conduct in-depth assessments of patient/family needs, coordinating input from all health professionals and formulating a documented plan to ensure continuity of care for at-risk patient populations.
- Develop and implement holistic health care assessments, including health risks assessment, patient preferences and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity, and social determinants of health.
- Delegate care based on the situation while assuming accountability for patient outcome, supporting assistive personnel, and serving as a resource and holding care team accountable to complete delegated tasks.
- Develop shared care plans and document on the Common Care Plan to allow access by all care team members across the care continuum.
- Perform outreach utilizing best practices to engage appropriate patients for care management.
- Advance Care Planning - Connect patients and surrogate decision makers to ACP facilitation process, ensuring that Advance Care Planning documents are stored and available within the EHR.
- Medication Management - Reconcile discharge medication orders, medication orders by specialists and PCP, collaborate with PCP/Interdisciplinary team members on medication changes as needed, and ensure patient understanding of any medications to stop taking or initiate.
- Psycho-social support - Identify complex behavioral or social needs, make appropriate referrals (SW, BH consultants, and community agencies/partners) through collaboration with physician (hospitalists/PCPs/specialists), leads and coordinates activities of interdisciplinary treatment team to evaluate progress, identify barriers, and opportunities to improve care.
- Coordinate and manage transitions of care across the continuum to assure appropriate utilization of clinical and community resources.
- Coordinate referrals processes from PCP to Specialty, provides oversight if patient transitions to SNF and monitor progress throughout the patient stay in collaboration with Post Acute internal and external care partners.
- Uses technology platform(s) to monitor and act upon changes in condition as directed by the primary care provider, ensuring post SNF transition plan is completed for Post-discharge call and follow up appointment is scheduled with PCP.
- Coordinates access to resources and supports to achieve the goals of care such as specialists, homecare, palliative, hospice and other community services.
- Initiates post transition phone calls to high risk / high vulnerability patients to assess self-management and to identify risk of readmission prior to their first appointment.
- Participate in quality improvement processes such as Readmission Root Cause Analysis, ED, and inpatient Hospitalization utilization reduction and mitigation efforts.
- Collaborates with the IP Team to align the appropriate resources and support systems to ensure successful transition to the outpatient setting, ensuring communication through warm hand off processes.
- Patient Education - Assesses patient/family knowledge and confidence level of chronic disease self-management and refers to internal and external resources to mitigate identified knowledge gaps, reinforces education regarding chronic disease self-management utilizing approved action plans, educational materials and best practice recommendations.
- Facilitates health and disease specific patient education utilizing Teachback methodology, empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization.
- Data Analytics - Identify appropriate risk stratification via EHR encounters or datasets to intervene as appropriate, integrates patient registry, stratification and other tools/reports to identify patients who may be appropriate for care management.
- College diploma in Nursing
- Registered Nurse (RN) licensure in Illinois
- Basic Life Support (BLS) certification
- Three (3) years clinical experience as a Registered Nurse
- Relevant clinical experience and current knowledge of healthcare trends, related to emerging care models related to population health management and achievement of the triple aim
- Basic computer knowledge using email, web browser, and documentation of care in an electronic health record
- Knowledge of the healthcare system and resources available to patients
- Strong clinical proficiency and ability to apply critical decision making in dynamic situations
- Motivational Interviewing and applies Chronic and Transitional Care Management skills
- Cultural compliance
- Trauma informed care
- Ability to problem solve in complex situations
- Strong interpersonal skills and ability to collaborate
- Excellent communication skills-written and verbal
- Strong self-motivation and ability to work independently, setting priorities to coordinate care plan efficiently
- Proven leadership skills
- Ability to function effectively as a team leader in a team-based environment
- Patient focused, excellent customer service skills
- Strong organizational skills and ability to efficiently use tools and resources
- Ability to perform multiple tasks
- Effective behavioral and educational strategies, including, but not limited to, motivational interviewing, teach-back method, and self-management support
