Registered Nurse Care Coordinator

2 weeks ago

Atlanta, Georgia, United States Whitefoord Health Center Full time
Job Overview

Position Title: Care Coordinator, RN

Department: Clinical Administration

Supervisor: Director of Clinical Quality, RN

Employment Status: Full-time, Exempt

The Care Coordinator plays a vital role in managing the care of high-risk and complex patients. This position emphasizes the importance of closing care gaps and supporting patients during transitions in their healthcare journey. The Care Coordinator serves as a guide and advocate, enhancing the patient's overall health and well-being. The focus is on reducing emergency room visits, minimizing hospital readmissions, and improving the management of chronic illnesses. This role involves facilitating access to necessary medical and specialty services while ensuring effective communication between patients and their primary care providers to achieve better health outcomes.

Key Responsibilities

Patient Care and Education:

  • Evaluates the physical, functional, social, psychological, and environmental needs of patients.
  • Provides essential education to patients and their caregivers regarding diagnoses, treatment options, illness progression, and self-care strategies.
  • Enhances continuity of care by fostering relationships with other healthcare providers and connecting patients with community resources.
  • Empowers patients in self-management and shared decision-making processes.
  • Conducts medication reconciliation as necessary in complex situations.
  • Advocates for patients and their families, ensuring respect for autonomy, dignity, and decision-making rights.
  • Actively engages in team meetings to support patient care management and participates in clinical quality and risk management discussions.
  • Facilitates referrals within the electronic health record (EHR) system.
  • Conducts community visits to better understand patients' healthcare challenges and to provide relevant community resources.
  • Collaborates with various clinic disciplines to ensure optimal patient care, including telephonic triage for high-risk patients when required.

Reporting and Compliance:

  • Maintains clear, concise, and timely documentation of all patient interactions in the EHR.
  • Ensures adherence to all practice policies and compliance with professional standards and regulatory requirements.
  • Develops, monitors, and reports on care coordination program activities for both internal and external stakeholders.
  • Completes additional tasks as assigned by the Clinical Operations Manager.

Qualifications

Education and Experience:

  • Bachelor's degree in Nursing; Registered Nurse.
  • Preferred experience in chronic disease management and patient education.
  • Familiarity with population health management principles.
  • Valid and unrestricted Registered Nurse license in Georgia.

Core Competencies:

  • Attendance and Punctuality: Consistently present and punctual; ensures responsibilities are managed during absences.
  • Communication: Communicates effectively in various situations; listens actively and responds to inquiries.
  • Customer Service: Addresses challenging customer/patient situations with professionalism; seeks feedback to enhance service quality.
  • Job Knowledge: Demonstrates competence in required skills and knowledge; adapts to new technologies and maintains confidentiality.
  • Problem Solving: Identifies and resolves issues promptly; analyzes information and develops alternative solutions.
  • Planning and Organizing: Prioritizes tasks efficiently; sets realistic goals and organizes activities effectively.
  • Quality Management: Strives for continuous improvement and accuracy in work; applies feedback constructively.
  • Safety and Security: Adheres to safety protocols and reports unsafe conditions promptly.
  • Teamwork: Fosters collaboration and maintains effective relationships with colleagues.

Physical Requirements:

The physical demands of this role require the ability to use hands frequently. Occasional standing, walking, and sitting are necessary, along with the ability to lift and/or move up to 25 pounds.

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