Clinical Nurse Care Coordinator

2 weeks ago


Laurel, Maryland, United States Somatus Full time
Clinical Nurse Care Coordinator

Overview
Somatus provides a flexible Hybrid Telehealth environment, combining remote work with in-person visits to patients' residences.

The Clinical Nurse Care Coordinator plays a vital role within a multidisciplinary care team, which includes nurses, dietitians, pharmacists, social workers, community health workers, and physicians.

This role involves close collaboration with patients experiencing complex renal conditions, engaging with them in their homes, dialysis centers, and through telecommunication as necessary.

The primary objective is to enhance patient outcomes by facilitating permanent access to care, advocating for home dialysis options and kidney transplantation, educating patients on self-management strategies, addressing risks associated with comorbidities, and coordinating comprehensive care.

Key Responsibilities

  • Perform thorough assessments encompassing medical, behavioral, pharmaceutical, and social needs of patients, identifying care gaps and health barriers; the Clinical Nurse Care Coordinator is expected to conduct around 12 assessments weekly and manage a caseload of approximately 150 patients.
  • Develop and implement personalized care plans in collaboration with the patient, their nephrologist, primary care physician, and other care team members based on assessment findings.
  • Act as an advocate and resource for patients, their families, and healthcare providers to ensure coordinated care.
  • Facilitate transitions of care across various settings, including home, hospital, skilled nursing facilities, and acute care environments.
  • Support patients during care transitions to ensure smooth handoffs and reduce avoidable readmissions.
  • Evaluate patients' understanding of their renal health and provide necessary education and self-management support.
  • Conduct ongoing evaluations and follow-ups to enhance patient outcomes.
  • Oversee non-licensed support staff, including community health workers and health coaches, as well as licensed professionals like social workers and renal dietitians, delegating tasks appropriately.

Measures of Success:

  • Strengthening provider relationships
  • Monitoring and coordinating dialysis interventions
  • Effective medical management
Qualifications
Required:
  • Minimum of 1 year of nursing experience in case management or care coordination, ideally across multiple healthcare settings.
  • Active Registered Nurse license.
  • Core values aligned with a patient-centered care philosophy.
  • Proactive patient advocacy and problem-solving skills.
  • Knowledge and experience to empower patients in self-management and collaborative decision-making.
  • Ability to work effectively within a team environment.
  • Strong written and verbal communication skills, demonstrating respect and cultural sensitivity in client interactions.
  • Robust analytical and critical thinking abilities, along with strong community engagement skills.
  • Willingness to travel within the assigned region and conduct home visits (up to 50% same-day travel).
Preferred:
  • Bachelor's Degree in Nursing.
  • Exhibits empathy, enthusiasm, a positive attitude, and a strong work ethic.
  • Experience working with diverse and vulnerable patient populations (e.g., ESRD, geriatrics, minorities, low-income, uninsured).
  • Ability to build rapport with patients and families through active listening and inquiry.
  • Familiarity with electronic medical records.
  • Experience in community outreach is preferred.
  • Proficiency in using MS Office applications and telecommunication devices.
Other Duties

This job description is not intended to be an exhaustive list of all responsibilities, duties, or tasks associated with the position. Responsibilities may change at any time with or without notice. The health and safety of our members, colleagues, partners, and community are our top priority. Proof of COVID-19 Vaccination is required for employment.

Somatus, Inc. is committed to providing equal employment opportunities to all individuals, regardless of race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, or any other characteristic protected by applicable law.

We also take affirmative action to ensure that applicants are employed and employees are treated fairly during employment without regard to any of these characteristics. Discrimination of any kind will not be tolerated.



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