Patient Care Coordinator RN

1 week ago

Dallas, Texas, United States Children's Health Full time

Position Title & Specialty Area:
Care Coordinator Specialty Center

Department:
Enterprise Care Management

Location:
Dallas

Shift:
Day

Job Type:
Onsite

Why Children's Health?

At Children's Health, our mission is to enhance the quality of life for children, recognizing that their health is vital to achieving this objective.


Through innovative treatments and collaboration with UT Southwestern, we aim to provide an exceptional experience for patients and their families, ensuring that every moment contributes positively to their overall health.

Our commitment to advancing children's health extends beyond our organization and into the wider community.

Together, we can significantly impact the lives of children and foster a healthier future for all.


Overview:


Utilizing advanced nursing expertise, the Care Coordinator is accountable for managing care throughout the healthcare continuum for a designated patient population.

Care Coordination within the healthcare system is a collaborative practice model.

In partnership with patients, families, and other caregivers, the Care Coordinator collaborates with a multidisciplinary team, including Providers, Nurses, Social Workers, financial counselors, and ancillary staff to facilitate the processes associated with navigating the patient through the continuum of care.

This role promotes continuity of care by advocating for the needs of patients and families, working with identified team members to enhance access to care, facilitate communication, and provide effective resource coordination during transitions to ensure quality and closure of care gaps.

Identifies and implements initiatives to enhance processes.

Key Responsibilities:

  • Responsible for prescribing, delegating, and coordinating patient care. Utilizes clinical judgment based on nursing skills acquired through formal and informal experience and evidence-based guidelines to assess the patient's situation and develop an appropriate care plan aimed at achieving optimal outcomes.
  • Ensures that patient care adheres to standards of safety, effectiveness, patient rights, and guest relations.
  • Oversees care provided by the patient care team; coordinates the care plan.
  • Provides education and facilitates learning for patients, families, and the care team in a manner that respects and incorporates diverse backgrounds.
  • Collaborates with physicians, families, and other healthcare professionals to develop and implement a suitable care plan that encourages contributions towards achieving the best patient outcomes.
  • Advocates for patients, addressing their concerns and assisting in resolving ethical and clinical issues.
  • Delivers care with a team-oriented approach, emphasizing strong customer relations, sound clinical judgment, and appropriate decision-making based on evidence-based practices.
  • Continuously evaluates the patient's condition through ongoing assessment and implements treatment adjustments as necessary in collaboration with the healthcare team, including the patient and family.
  • Maintains a comprehensive knowledge base and tools to manage available resources for patients and families across healthcare and non-healthcare systems.
  • Care Coordination /

Disease Management:

  • Conducts and analyzes comprehensive assessments during patient intake.
Coordinates treatment plans involving payors, supplies, equipment, medications, in-house services, and community resources.

  • Collaborates with the healthcare team on care plans, referrals, and ongoing patient needs.
Ensures that consults, testing, and procedures are appropriately sequenced to align with the patient's clinical condition and facilitate timely care delivery. Intervenes and resolves barriers to service as needed.

  • Utilizes disease-specific clinical pathways to ensure effective clinical management.
Assesses educational needs of patients, families, and caregivers, considering barriers to care (e.g., literacy, language, cultural influences, comorbidities).

  • Ensures that education regarding clinical processes has been provided by the healthcare team.
Coaches patients and families towards lifestyle changes and effective self-management of chronic conditions.

  • Demonstrates customer-focused interpersonal skills, employing problem-solving and critical thinking.
Facilitates communication and coordination of care plans with Providers and the healthcare team.

  • Participates in developing strategies to optimize service utilization in assigned areas.

Resource Management:

  • Advises patients, families, and the organization on cost-effective care options based on relevant clinical information.
Navigates payor benefits and assists patients and families in understanding insurance plan benefits and financial implications during transition management and discharge planning.

  • Understands the organizational impact and utilizes knowledge of Diagnosis Related Groupings and estimated length of stay when developing discharge plans.
Recognizes the negative impact of readmissions on patients and the healthcare system, engaging in root cause analysis and implementing strategies to prevent readmissions.

  • Discharge Planning /

Transition Management:

  • Identifies and addresses actual and potential barriers to service or treatment, collaborating with appropriate resources across the continuum of care.
Evaluates the patient's response to pharmacological and therapeutic regimens with the team.

  • Works with multidisciplinary staff to ensure patients and families receive appropriate information and education prior to transitioning to the next level of care.
Identifies and resolves discharge needs, implementing a coordinated plan for safe and timely discharge.

  • Ensures consensus on the care plan among patients, families, healthcare teams, and payors.
Advocates, mediates, and negotiates to formulate a cohesive plan for maintaining or enhancing patient health status during transitions.

  • Communication:
Communicates and resolves conflicts with Providers, healthcare team members, community agencies, clients, and families with diverse opinions and values.

  • Builds therapeutic and trusting relationships with patients, families, and caregivers through effective communication and listening skills.
Maintains ongoing communication with patients and families, Providers, multidisciplinary team members, and payors to facilitate coordination of clinical activities and enhance seamless transitions across the continuum of care.

  • Managing Key Performance Indicators (as defined by the hiring manager):
Works to enhance quality by reducing treatment delays, utilizing clinical pathways, and monitoring quality indicators.

  • Provides ongoing consultation and training to medical staff and other healthcare professionals on discharge and home care issues; participates in process improvement initiatives; identifies barriers in service delivery systems and develops improvement processes.
Strives to increase quality, efficiency, and patient satisfaction while managing care costs for the targeted population.

  • Collects, completes, and submits statistical data promptly.

Professional Development:

  • Remains current on EMTALA and regulatory requirements.
Stays informed about payor guidelines and standards.

  • Keeps abreast of community resources available to facilitate safe patient transitions of care.
Stays updated on clinical advancements related to the primary patient population.

  • Proactively seeks to understand roles outside of immediate responsibilities within the department.
Engages in community involvement and advocacy, participating in health fairs and relevant professional organizations.
WORK EXPERIENCE

  • Minimum of 4 years in Pediatric nursing, Case Management, Care Management, Care Coordination, Utilization Review, or Community-based nursing required.

EDUCATION

  • Bachelor's degree required.

LICENSES AND CERTIFICATIONS

  • Registered Nurse in the State of Texas required upon hire.
  • Accredited Case Manager (ACM) or Certified Case Manager (CCM) or Care Coordination and Transition Management (CCTM) preferred upon hire.
  • Effective 7/1/2023, Basic Life Support for Healthcare Providers as required by CP 1.20 Life Support Course Requirements.
A Place Where You Belong

We prioritize our people. We value and respect the beliefs, identities, and experiences of our patients and colleagues.

We are dedicated to delivering culturally effective care, fostering meaningful partnerships in the communities we serve, and equipping our team members to make Children's Health a place where everyone can contribute.

Holistic Benefits - How We'll Care for You:

  • Employee portion of medical plan premiums are covered after 3 years.
  • 4%-10% employee savings plan match based on tenure.
  • Paid Parental Leave (up to 12 weeks).
  • Caregiver Leave.
  • Adoption and surrogacy reimbursement.

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