Registered Nurse
13 hours ago
The RN Coordinator serves as the key contact point for patients to coordinate and streamline all services offered within Evernorth Health Services. This role requires a compassionate and positive individual who inspires confidence in patients. The RN Coordinator will work hand-in-hand with patients, other staff, and providers to answer questions and provide education on healthcare options.
Core Responsibilities- Be the point of contact for all aspects of the member in regard to their appointments, care, and overall health.
- Act as the liaison between providers and their patient panel, directing and delegating tasks to team members.
- Provide education to patients about their care options and make specific recommendations based on their goals.
- Review paperwork for patients to ensure it meets all requirements.
- Explain test results, diagnoses, and other medical outcomes.
- Cover any additional triage and transition of care for patients as needed.
- Improve health literacy and coach patients on chronic conditions, including disease process and trajectory, medication education, and plan of care.
- Identify problems or gaps in care and offer opportunities for intervention.
- Coordinate services and referrals to health programs and participate in patient education and outreach tied to HEDIS initiatives.
- Work to improve access to care and manage healthcare costs and utilization.
- Complete telephonic nursing assessments, including social determinants of health screenings, post-hospital discharge screenings, triage, and other assessments assigned by providers.
- Assist with organizing and running chronic care and/or interdisciplinary care team rounds where high-risk patients and care plans are identified.
- Participate in a team approach to create a care plan for patients.
- Maintain and update spreadsheets and documents provided by health plans to prepare weekly rounds of documentation.
- Participate in weekly care coordination with health plan case management as directed by market needs.
- Referral management, care coordination, and tracking of hospice consults within 24 hours of order placement.
- Obtain pre-authorization for all CT, MRI, Echo's ordered by providers.
- Serve as a guide in their POD for all escalated orders and results as clinically appropriate.
- Assess and triage immediate health concerns transferred to the nursing team by clinical support staff.
- Provide telephonic nursing assessment and triage supported by triage protocols.
- Initiate medication changes and other orders, as directed by providers in response to a triage call.
- Monitor daily discharge lists and develop a plan to schedule transition of care visits within the allotted timeframe.
- Complete telephonic post-discharge hospital visits and ask pertinent discharge triage questions and complete medication reconciliation.
- Document all findings and make appropriate referrals to social work, pharmacy, case management, and engagement.
The ideal candidate will possess the following competencies:
- Communicates Effectively - Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
- Manages Ambiguity - Operating effectively, even when things are not certain or the way forward is not clear.
- Courage - Stepping up to address difficult issues, saying what needs to be said.
- Manages Complexity - Making sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.
- Demonstrates Self-Awareness - Using a combination of feedback and reflection to gain productive insight into personal strengths and weaknesses.
- Situational Adaptability - Adapting approach and demeanor in real-time to match the shift in demands of different situations.
- Collaborates - Building partnerships and working collaboratively with others to meet shared objectives.
- Active, unrestricted RN license in all states we provide services.
- Ability to obtain compact license and/or additional state licensure as needed.
- 3+ years of experience as a Registered Nurse.
- Proficient level of experience with Microsoft Office applications and strong technical aptitude.
- EMR experience and proficiency.
- BSN or ADN degree.
- Previous experience working with the geriatric population or chronic condition experience.
- Home Health experience.
- Triage experience.
- Case management experience.
- Previous customer service experience.
- Previous experience in a telephonic role.
- Highly organized, self-directed worker with an ability to function in a high-volume environment.
- Strong verbal and written communication skills.
- Prior clinical experience in palliative care, end-of-life, hospice, oncology, ICU, geriatrics is preferred.
- Knowledge of STARS and Hedis metrics a plus.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions, including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status, or any other characteristic protected by applicable equal employment opportunity laws.
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