RN Care Coordinator Outpatient Specialist

2 weeks ago


Newport News, Virginia, United States Riverside Health System Full time
Job Summary

We are seeking a highly skilled and compassionate RN Care Coordinator Outpatient to join our team at Riverside Health System. As a key member of our healthcare team, you will be responsible for coordinating care to patients who are considered high risk with complex medical and psycho-social needs.

Key Responsibilities
  • Develops an appropriate patient-specific Care Plan to include short and long term goals, objectives and actions and partners with the patient and family in the development of the plan of care.
  • Coordinates, collaborates, and obtains approval of the plan with the patient, family/caregiver, primary provider and other members of the healthcare team.
  • Guides the patient and family/care giver through the healthcare system, maximizing use of resources.
  • Coordinates and executes the plan of care, optimizing access to appropriate services.
  • Serves as an advocate for, and ensures education is provided to, the patient and family/caregiver as required.
  • Collaborates with the patient's PCP and specialists in the development of the plan of care to ensure the patient's needs are addressed; communicates care objectives to appropriate individuals/departments/referral sources.
  • Proactively identifies and evaluates patients and families for care management from a variety of sources such as RHS internal reports, discharge/disposition planning, referrals, the healthcare system, employers and facility staff.
  • Assess and document clinical and psychosocial patient needs.
  • Conducts systematic, on-going, thorough collection of patient's physical, emotional, psychological, social and medical status and information via direct patient contact and other relevant sources such as professional and non-professional caregivers, medical records, family/caregiver interviews.
  • Reviews the patients' health insurance benefits to determine services available.
  • Evaluates the quality and necessity of health care services and makes recommendations for an alternative level of care when appropriate.
  • Execution of the interventions established that lead to accomplishing the goals set forth in the plan of care.
  • Ensures coordination of care delivery processes, to include alternate healthcare settings and the home environment, for the purposes of enhancing the patient's health and wellness, safety, productivity, and quality of life, and for providing the most beneficial, cost-effective health care.
  • Develops, utilizes and maintains a variety of community resources to optimize access to services and medical care.
  • Utilizes appropriate patient education materials.
  • Ensures timely and appropriate provision of services.
  • Anticipates the patient's needs and encourages patients and families to actively participate in the plan of care.
  • Establishes working relationships with referral sources and community resources.
  • Documents and updates the Care Plan as needed.
  • Maintains documentation and data collection in accordance with RHS policies and procedures.
  • Conducts and/or participates in program evaluation as directed.
Requirements
  • Education: Nursing (Required), Associates Degree, Sociology/Social Work/Nursing (Required), Bachelors Degree, Sociology/Social Work/Nursing (Preferred)
  • Experience: 1-3 years Acute care nursing (Required), 1-3 years Case management and health care delivery experience (Preferred)
  • Licenses and Certifications: Registered Nurse (RN) - Virginia Department of Health Professions (Required), CPR/BLS Certification - American Heart Association/American Red Cross/American Safety and Health Institute (AHA/ARC) (Required), Accredited Case Manager (ACM) - American Case Management Association (ACMA) (Preferred), Driver's License (Required)


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