Care Coordinator RN

2 days ago

Canton, New York, United States Rochester Regional Health Full time
Job Summary

The Care Coordinator RN is responsible for coordinating patient care services to help reduce costs by reducing duplication of services. This role requires a strong understanding of healthcare systems and the ability to communicate effectively with patients, families, and healthcare providers.

Key Responsibilities
  • Systematically identifies individual patients and plans, manages and coordinates their care, based on condition, needs and on evidence-based guidelines based on quality goals of organizations and population needs.
  • Provides assessment, care planning and coordination, and advocacy to patients and their families.
  • Develops, formulates, implements, and revises self-management care plans with a shared-goal model, incorporating patient specific education as appropriate for high risk patients and others, as defined by the practice.
  • Evaluates patient responses to interventions, identifying and developing strategies to barriers in achieving positive clinical outcomes.
  • Coordinates care with community and regional ancillary health services for extended needs of patients and ensures that patient specific care plans are developed and documented by the practice clinical team.
  • Educates patient/family regarding relevant wellness issues, disease process, and treatment plan, if not bringing to the attention of the physician.
  • Educates patients with appropriate method suitable for individual learning abilities regarding diet, medication, or test needs, if not bringing to the attention of the physician.
  • Serves as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
  • Promotes timely access to appropriate care.
  • Increases utilization of preventative care.
  • Reduces emergency room utilization and hospital readmissions.
  • Increases comprehension through culturally and linguistically appropriate education.
  • Creates and promotes adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).
  • Increases continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
  • Tracks and reports on patient progress.
  • Manages referrals, when needed, to appropriate agencies required to assist the patient in achieving the goals and objectives defined in their Care Plan.
  • Defines and directs patients and/or families to appropriate resource utilization.
  • Increases patients' ability for self-management and shared decision-making.
  • Connects patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, reduce social barriers to care, and decrease health care costs.
  • Assists patients in problem solving potential issues related to the health care system, financial or social barriers (e.g. request interpreters as appropriate, transportation services, or prescription assistance).
  • Assists with data collection and generation of patient registry reports.
  • Attends and participates in team/educational conferences as needed.
  • Care Delivery: Maintains safe and effective nursing care rendered directly or indirectly, adjusting nursing care processes as necessary to ensure optimal patient care.
  • Triage patient phone calls.
  • Provides medication reconciliation.
  • Pre-Visit planning prior to physicals of patients identified in registry.
  • Performs RN-Led Annual Wellness Visits.
  • Makes adjustments in patients' medications following physician directed guidelines to achieve therapeutic levels. Evaluates patient response to those interventions.
  • Places orders for lab tests, immunizations or ancillary testing per protocol, under provider guidance.
  • Assists & manages follow-up care as requested by Primary Care physician.
  • Leads patient care team in daily and/or weekly huddle discussions to prepare for the day or week ahead.
  • Works closely with community resources to coordinate care needed by high risk patients, as defined by the practice.
  • Under direction of practitioners, communicates test results and care plans to patients/families.
  • Assists and completes various forms for the patient.
  • Responsible for coordinating and leading patient support groups and/or shared medical appointments.
  • Quality & Regulatory: Participates in Performance Improvement/Continuous Quality Improvement activities, as assigned.
  • Works with PPM management team to comply with all established standards and regulations per DNV standards and hospital compliance requirements.
  • Works with PPM management team to resolve clinical issues (processes, performance, etc.) to identify opportunities for improvement.
  • Adheres to CPH and PPM policies and procedures, protocols, guidelines, etc.
  • People: Serves as a mentor and a resource provider for clinic and hospital staff.
  • Provides education to patients and significant others, as well as staff.
  • Maintains a level of communication that exceeds the person's expectations in every encounter.

Education:

Licenses/Certifications:

Physical Requirements:
M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee's physician or delegate will be considered for accommodations.

Pay Range:
$52.88

City:
Canton

Postal Code:
13617

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity/Affirmative Action Employer.

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