RN Care Coordinator: Population Health & Transitions

Overview

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 vulnerable at times of transition between care settings. Cross‑continuum care managers create longitudinal, personalized care plans for patients, families, and support systems, 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, reduce the cost of care, and improve clinical outcomes.

Certifications:

Licensed Registered Professional Nurse (RN) – Illinois Department of Financial and Professional Regulation (IDFPR);
Basic Life Support (BLS) within 30 days – American Heart Association (AHA).

Education:

College Diploma in Nursing;
Bachelor’s Degree in Nursing.

Work Experience:

2+ years of nursing.

Conduct in‑depth assessments of patient/family needs by coordinating input from all health professionals and formulating a documented plan that assures continuity of care for at‑risk patient populations. The holistic health care assessment includes health risks assessment, patient preferences and goals, health literacy, patient engagement level, patient confidence to perform self‑management, impact of chronic health conditions and comorbidities, and social determinants of health.

Delegate care based on the situation while assuming accountability for patient outcomes. Support assistive personnel; serve as a resource and hold the care team accountable to complete delegated tasks. Develop a shared care plan and document it on the Common Care Plan to allow access by all care team members across the continuum.

Perform outreach utilizing best practices to engage appropriate patients for care management.

Advance Care Planning – connect patients and surrogate decision makers to ACP facilitation. Ensure that Advance Care Planning documents are stored and available within the EHR.

Medication Management – reconcile discharge medication orders, medication orders by specialists and PCPs. Collaborate with PCPs and interdisciplinary team members on medication changes as needed. Ensure patient understanding of any medications to stop or initiate. Explain why medications were discontinued.

Psychosocial support – identify complex behavioral or social needs; make appropriate referrals (social workers, behavioral health consultants, community agencies/partners) through collaboration with physicians (hospitalists/PCPs/specialists). Lead and coordinate activities of the interdisciplinary treatment team to evaluate progress, identify barriers, and opportunities to improve care.

Coordinate and manage transitions of care across the continuum to assure appropriate utilization of clinical and community resources. Coordinate referral processes from PCP to specialty; provide oversight if a patient transitions to SNF and monitor progress throughout the patient’s stay in collaboration with post‑acute internal and external care partners. Use technology platforms to monitor and act upon changes in condition as directed by the primary care provider.

Ensure post‑SNF transition plans are completed and post‑discharge calls and follow‑up appointments are scheduled with PCP.

Coordinate access to resources and supports to achieve the goals of care such as specialists, home care, palliative care, hospice, and other community services.

Initiate post‑transition phone calls to high‑risk/high‑vulnerability patients to assess self‑management and identify risk of readmission before their first appointment.

Participate in quality improvement processes such as readmission root‑cause analysis, ED utilization reduction, and inpatient hospitalization utilization mitigation efforts.

Collaborate with the IP team to align resources and support systems to ensure successful transition to the outpatient setting. Ensure communication through warm hand‑off processes.

Patient education – assess patient/family knowledge and confidence in chronic disease self‑management and refer to internal and external resources to…