Job Description

JOB SUMMARY:
*Hybrid position after successful completion of orientation*


The Care Coordinator RN is responsible for providing care management and population health services to patients within the assigned region. Primary target populations include those at high risk and vulnerability at times of transition between care settings. Cross-continuum care managers create longitudinal, personalized care plans for patients/family/support system, collaborate with and coordinate the efforts of care across the continuum. Consistently using data analytics to manage the health of populations to improve patient access to care, reduction in cost of care, and improved clinical outcomes.

EDUCATIONAL REQUIREMENTS
College diploma Nursing

CERTIFICATION & LICENSURE REQUIREMENTS
Registered Nurse (RN) Illinois and Basic Life Support (BLS)

EXPERIENCE REQUIREMENTS
Three (3) years clinical experience registered Nurse. Relevant clinical experience and current knowledge of healthcare trends, related to emerging care models related to population health management and achievement of the triple aim.

SKILLS AND KNOWLEDGE
Basic computer knowledge using email, web browser and documentation of care in an electronic health record. Knowledge of the healthcare system and resources available to patients. Strong clinical proficiency and ability to apply critical decision making in dynamic situations. Motivational Interviewing and applies Chronic and Transitional Care Management skills. Cultural compliance. Trauma informed care. Ability to problem solve in complex situations. Strong interpersonal skills and ability to collaborate. Excellent communication skills-written and verbal. Strong self-motivation and ability to work independently, setting priorities to coordinate care plan efficiently. Proven leadership skills. Ability to function effectively as a team leader in a team-based environment. Patient focused, excellent customer service skills. Strong organizational skills and ability to efficiently use tools and resources. Ability to perform multiple tasks. Effective behavioral and educational strategies, including, but not limited to, motivational interviewing, teach-back method, and self-management support.

ESSENTIAL FUNCTIONS:

• Conducts in depth assessments of patient/family needs by coordinating input from all health professionals and formulating a documented plan assuring continuity of care for at risk patient populations. Holistic health care assessment includes: health risks assessment, patient preferences and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity, and social determinants of health.
• Delegates care based on the situation while assuming accountability for patient outcome. Supports assistive personnel; serves as a resource and holds care team accountable to complete delegated tasks. Develops shared care plan and document on the Common Care Plan to allow access by all care team members across the care continuum. Performs outreach utilizing best practices to engage appropriate patients for care management.
• Advance Care Planning- Connects patient and surrogate decision maker to ACP facilitation process. o Ensure that Advance Care Planning documents are stored and available within the EHR
• Medication Management -Reconcile discharge medication orders, medication orders by specialists and PCP. Collaborate with PCP/Interdisciplinary team members on medication changes as needed. Ensure patient understanding of any medications to stop taking or initiate. Be clear to patients why medications were discontinued.
• Psycho-social support ? Identify complex behavioral or social needs; make appropriate referrals (SW, BH consultants, and community agencies/partners) through collaboration with physician (hospitalists/PCPs/specialists), leads and coordinates activities of interdisciplinary treatment team to evaluate progress, identify barriers, and opportunities to improve care.
• Coordinates and manages transitions of care across the continuum to assure appropriate utilization of clinical and community resources.
• Coordinate referrals processes from PCP to Specialty; Provides oversight if patient transitions to SNF and monitor progress throughout the patient stay in collaboration with Post Acute internal and external care partners. Uses technology platform(s) to monitor and act upon changes in condition as directed by the primary care provider. Ensure post SNF transition plan is completed for Post-discharge call and follow up appointment is scheduled with PCP. Coordinates access to resources and supports to achieve the goals of care such as specialists, homecare, palliative, hospice and other community services.
• Initiates post transition phone calls to high risk / high vulnerability patients to assess self-management and to identify risk of readmission prior to their first appointment.
• Participate in quality improvement processes such as Readmission Root Cause Analysis, ED, and inpatient Hospitalization utilization reduction and mitigation efforts.
• Collaborates with the IP Team to align the appropriate resources and support systems to ensure successful transition to the outpatient setting. Ensure communication through warm hand off processes.
• Patient Education - Assesses patient/family knowledge and confidence level of chronic disease self -management and refers to internal and external resources to mitigate identified knowledge gaps. Reinforces education regarding chronic disease self- management utilizing approved action plans, educational materials and best practice recommendations. Facilitates health and disease specific patient education utilizing Teachback methodology. Empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization.
• Data Analytics- Identify appropriate risk stratification via EHR encounters or datasets to intervene as appropriate. Integrate patient registry, stratification and other tools/reports to identify patients who may be appropriate for care management.
• Manages revolving patient pan

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