Care Coordinator; RN

Description

Memorial Community Health, Inc. is seeking an individual to fill the position of Care Coordinator (RN) at Memorial Health Clinic in Aurora. This is full-time days, Monday through Friday.

This individual will coordinate team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered. In this position, you will work with Chronic Care Management and Transitional Care Management patients.

• Provides a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population
• Implements an effective internal tracking system for identified patients
• Coaches patients/families toward successful self-management of their chronic disease
• Utilizes tools and documents that support a guided care process, collaborates with patient/family toward an effective plan of care
• Assesses patient and family’s unmet health and social needs
• Provides effective communications to improve health literacy
• Promotes healthy behaviors in all populations and ensures assistance with community resources
• Facilitates patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator)
• Cultivates and supports primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care referrals
• Serves as the contact-point, advocate, and informational resource for the patient, family, care team, payers and community resources
• Ensures effective tracking of test results, medication management, and adherence to follow-up appointments
• Develops systems to prevent errors (e.g., effective medication reconciliation and shared medical records)
• Follows HIPAA regulations and ensures that the confidentiality of patients’ medical, personal, financial records, employee records, and organizational records is maintained.
• Complies, understands, and enforces state and federal regulatory requirements related to the performance of Memorial Community Health operations and requirements, including but not limited to HIPAA, the Code of Conduct, the Compliance Policy, Safety and Infection Control, all department and organization-wide policies, Critical Access Hospital requirements, and Federal and State of Nebraska regulations.
• Performs other duties as assigned.

• Previous experience caring for chronic disease patients
• BSN preferred
• 3-5 years of experience in clinical or community health settings preferred
• Previous Care Coordination, Case Management or Home Health experience preferred
• Currently licensed as a Registered Nurse the State of Nebraska
• Basic Life Support (BLS)