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CARE COORDINATOR RN

Summary

Coordinates care for high-risk patients in a primary care clinic, partnering with providers and families to manage chronic conditions, reduce hospital readmissions, and improve patient outcomes using EHR and community resources.

Location/Department: Physician's Center - Primary Care

80 hours per pay period - benefit eligible

Job Summary:

The Care Coordinator works in collaboration & continuous partnership with chronically ill or “high-risk” patients & their families, clinic/hospital providers & staff, & community healthcare resources in a team approach to: promote timely access to appropriate care; increase utilization of preventative care; reduce ED utilization & hospital readmissions; increase comprehension through culturally – & linguistically – appropriate education; create & promote adherence to a care plan, developed in coordination with the patient & the patient/family; increase continuity of care by managing relationships with tertiary care providers, transitions-in-care & referrals; increase patients’ ability for self-management & shared decision-making; provide medication reconciliation; connect patients to relevant community resources; with a goal of enhancing patient & family health & well-being, increasing patient satisfaction & reducing costs.

Supervisory Responsibilities: None

Duties/Responsibilities:

  • Uses only approved abbreviations.
  • Understands patient safety goals & actions taken.
  • Uses 2 patient identifiers before giving treatments, demonstrates process.
  • Understands read back of verbal orders/critical lab values & can state process.
  • Understands procedure to clarify physician orders.
  • Uses standing orders when indicated.
  • Accurately calls report to MD as warranted by condition; reports to other providers as needed.
  • Reports sentinel events or adverse drug reactions or incidents as warranted.
  • Uses final verification before invasive procedures & can verbalize correct process & documents in EHR.
  • Reassesses patient in response to changes in condition after intervention as needed & documents in EHR.
  • Attend all Care Coordinator training webinars & meetings.
  • Provide feedback for the improvement of the Care Coordination program.
  • Assist with the identification of “high-risk” patients (the chronically ill & those with special health care needs).
  • Work with patients to plan & monitor care; assess patient & family’s unmet health & social needs; develop a care plan with the patient, family & providers (emergency plan, medical summary, & ongoing action plan as appropriate); monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely way & facilitate changes as needed; create ongoing processes for patients & families to determine level of care coordination support they desire at any given point in time.
  • Serve as the contact-point, advocate & informational resource for patient, family, payers & community resources.
  • Facilitate patient access to appropriate medical & specialty providers.
  • Educate patient & family about relevant community resources.
  • Cultivate & support primary care & subspecialty co-management with timely communication, inquiry, follow-up, & integration of information into the care plan regarding transitions-in-care & referrals.
  • Facilitate & attend meetings between patient, family, care team, payers & community resources as needed.

Required Skills/Abilities:

  • Demonstrates professional, appropriate, effective & tactful, written, verbal & nonverbal communication skills.
  • Demonstrates a positive attitude & respectful, professional customer service.
  • Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, & follows HIPAA guidelines & regulations.
  • Proactively acts as patient advocate, responding with empathy & respect to resolve patient & family concerns, & recognizes opportunities for improvement to meeting patient concerns.
  • Proactively continues to educate self on providing quality care & improving professional skills.
  • Effectively communicates both verbal & written.

Education and Experience:

  • Minimum Associates degree in nursing, Bachelor’s degree preferred
  • Minimum of 2 years relevant work experience required
  • Must be licensed as a Registered Nurse in the state of Indiana

Physical Requirements:

  • Frequent walking, standing, pushing, pulling, stooping, kneeling, reaching, talking, & use of hands
  • Occasionally may need to lift up to 25 lbs
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