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Registered Nurse Care Coordinator
2 months ago
Location:
Aledade
Position:
Registered Nurse Care Coordinator
Primary Responsibilities:
Our objective is to deliver the highest standard of healthcare to patients in a compassionate environment. This includes acknowledging the significance of exceptional customer service for patients, visitors, and staff.
Key Duties:
- Operate autonomously in a secure and suitable manner.
- Exhibit sensitivity and understanding towards the needs of patients, visitors, and staff.
- Recognize the value of time and respond swiftly to the needs of patients, visitors, and staff.
- Work meticulously with a focus on detail.
- Prioritize care delivery and leverage resources to enhance efficiency.
- Fulfill position requirements.
- Assess and implement changes to address patient needs.
Overview of Major Functions:
Registered Nurses are accountable for providing safe, timely, and appropriate patient care through the application of the nursing process.
The Registered Nurse is expected to understand and comply with all institutional and departmental policies and procedures, as well as the standards set forth in the relevant Nurse Practice Act.
The Registered Nurse oversees the direction and guidance of support personnel activities within the units.The Registered Nurse delivers personalized care, education, and support that addresses the immediate and anticipated needs of patients and their families throughout the care continuum.
The Registered Nurse coordinates team-based care to deliver health services to individuals, fostering effective partnerships with patients, their caregivers/families, community resources, and their healthcare providers.The Registered Nurse promotes a collaborative model within and across settings to achieve coordinated, high-quality care that is centered around patients and their families.
Patient Care:
The nursing process is employed to conduct comprehensive, age-appropriate nursing assessments, including biophysical, psychological, social, and educational needs.
Assessment of patients' learning needs, abilities, preferences, and readiness to learn, considering cultural and religious practices, emotional barriers, and financial implications of care choices.
Patient assessment and interviews are utilized to develop an individualized care plan within the guidelines of the Nurse Practice Act and institutional policies.
Implementation of all clinical and technical aspects of the individual patient care plan, including adherence to proper techniques, infection control guidelines, and established procedures/safety precautions to meet the unique needs and priorities of the patient.
Provide accurate and timely documentation of nursing interventions, patient responses, and evaluations, along with further actions if necessary.
Evaluation:
Review and assess the patient care plan through continuous patient evaluation.
The care plan is coordinated in consultation with a multidisciplinary team and adjusted to ensure seamless delivery of care across the continuum.
Ongoing evaluation of patient care will include continued involvement of patients and families, adjusting to meet evolving biophysical, psychological, social, and educational needs.
Professional Conduct:
Support and contribute to the mission and vision of Aledade with a continuous focus on excellence in customer service and patient care delivery.
Adhere to institutional, departmental, and compliance policies, procedures, regulations, and laws.
Ensure confidentiality of patient information at all times.
Perform additional duties as required within the scope of practice to support departmental and institutional needs.
Duties and Responsibilities:
- Provide a coordinated approach to identify and manage the chronically ill patient population effectively.
- Implement an internal tracking system for identified patients.
- Guide patients and families towards successful self-management of chronic diseases.
- Utilize tools and documents that support a guided care process, collaborating with patients and families to develop an effective care plan.
- Assess unmet health and social needs of patients and families.
- Enhance communication to improve health literacy.
Develop a care plan based on mutual goals with the patient, family, and provider's emergency plan, medical summary, and ongoing action plan, as appropriate.
Monitor patient adherence to the care plan and progress towards goals in a timely manner, facilitating changes as necessary.
Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists.
Foster and support primary care and subspecialty co-management through timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions in care and referrals.
Facilitate and attend meetings between patients, families, care teams, payers, and community resources as needed.
Participate actively in all Care Coordination related training and meeting activities.
Position Competencies:
- Core values aligned with a patient/family-centered approach to care.
- Demonstrates professional and effective written and verbal communication skills.
- Exhibits a positive, respectful attitude and professional customer service.
- Acknowledges patients' rights regarding confidentiality, maintaining patient confidentiality at all times, and adhering to relevant guidelines and regulations.
- Proactively acts as a patient advocate, responding with empathy and respect to resolve patient and family concerns.
- Recognizes and responds to opportunities for improvement.
- Demonstrates continual learning skills, adapting care approaches based on established, evidence-based practices.
- Provides mentoring and coaching to other population health and care coordination team members.
Foster effective partnerships and collaborate with all practice providers.
Exhibits effective delegation skills to streamline operational workflows and optimize inter-office resources.
Physical Environment:
Exposure to all patient elements, including exposure to human waste. Long and irregular hours may be necessary. Exposure to hazardous substances may occur.
Frequently, multiple tasks and patient needs must be addressed rapidly, prioritizing life-threatening situations and organizing the remainder of the needs.
Education:
- Must be currently licensed or eligible for licensure as a Registered Nurse.
- Must be a graduate of an accredited nursing program.
- Bachelor of Science in Nursing preferred.
Experience:
- Previous experience in managing chronic disease patients is required. 3-5 years of experience in clinical or community health settings is preferred.
- Previous experience in Care Coordination, Case Management, or Home Health is preferred.
- Demonstrates essential leadership, communication, education, collaboration, and counseling skills.
- Proficient in communication technologies.
- Must possess the ability to communicate compassionately with patients, families, visitors, and office staff.
- Must have the ability to interact well with people and manage stressful situations appropriately.
- Ability to identify and implement effective patient communication strategies and overcome accessibility barriers as required.
- Effective organizational skills and demonstrates the ability to maintain accurate notes and records.
- Previous experience with health IT systems and data reports is preferred.
- Must have the ability to understand medical records and provider orders.
- Previous experience with mobilizing community resources and navigating patients through the healthcare continuum is preferred.
- Ability to speak a relevant second language is preferred.
- Must be flexible and able to work as a team member.
- Basic Cardiac Life Support Certification is required.
- All staff may be required to float within the parameters of orientation and institutional policy.
