RN Care Coordinator

6 days ago

MA United States South Shore Health Full time
Job Title: RN Care Coordinator

South Shore Health is seeking a highly motivated and experienced RN Care Coordinator to join our team. As a RN Care Coordinator, you will play a critical role in coordinating care to specific at-risk patient populations within our health system.

Job Summary:

The RN Care Coordinator will work under the general supervision of the Manager of Care Progression to coordinate care to specific at-risk patient populations within the South Shore Health system of care. This role will work in close collaboration with the population health, innovation, and care progression teams to deliver clinically-based, goal-oriented care coordination aimed at engaging patients in chronic disease management activities, reducing risk for hospitalization and/or re-hospitalization, and overall total cost of care.

Key Responsibilities:
  • Navigate and coordinate care for patients with complex needs
  • Work within risk stratification methodologies to outreach and engage eligible patients into defined care programs
  • Connect with risk-stratified or referred patients in acute care, primary care, and community settings to represent innovation programs and assist in developing initial care plans
  • Craft patient-centered care plans based on evidence-based best practices for chronic disease management and transitions of care, with clearly outlined programmatic goals for care
  • Identify and help coordinate patient engagement into transitional, complex, and advanced illness care management programs as appropriate
  • Participate in weekly team care coordination reviews
  • Provide care coordination follow-up for a panel of patients with interventions, including referrals to community programs
  • Communicate plans with physicians, unit-based case management teams, patients, care plan partners, primary care physicians, and healthcare teams
Requirements:
  • BSN required; Master's of Science in Nursing preferred
  • 5-8 years of experience as a Med/Surg/Critical Care/Home Care RN, with experience in community care settings/VNA preferred
  • Experience with motivational interviewing, patient education/engagement, and population health management preferred
  • RN - Registered Nurse licensure required
  • ACM - Accredited Case Manager or CCM - Certified Case Manager certification within two years of hire
Preferred Qualifications:
  • Bilingual (Spanish) preferred
  • Strong interpersonal skills, care planning, care management, and utilization skills
  • Ability to adapt to changing priorities and regulations
What We Offer:

South Shore Health offers a competitive salary and benefits package, as well as opportunities for professional growth and development. If you are a motivated and experienced RN Care Coordinator looking for a new challenge, we encourage you to apply.

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