Continuing Care Coordinator RN

** Job Summary and Responsibilities*
* As a RN Care Coordinator, you will be a central figure in patient care, seamlessly navigating the healthcare journey to achieve optimal outcomes and an exceptional patient experience.

Every day, you will strategically assess, plan, and facilitate comprehensive care across the continuum, expertly advocating for patients while collaborating with physicians, nursing, departments, insurers, and post-acute providers to ensure timely, high-quality transitions.

To be successful in this role, you will possess strong clinical acumen, exceptional communication and advocacy skills, and a strategic mindset, all driven by a passion for optimizing patient care across every touchpoint.

+ Assessment Works with "at risk" patients and families on self-management support including:

Performing individual needs assessment, care plan design, education, documentation, implementation, and evaluation of outcomes according to state and national guidelines, policies, procedures, and protocols as required.

Following evidence-based care pathways

Coordinating care across multiple provider sites and interdisciplinary teams

Working with patients to create a plan of care for health behavior change:

Assessing and working on the patient's readiness to change, the importance of change, and confidence in ability to change

Helping the patient to identify and overcome barriers

Setting short and long-term goals for self-management of chronic disease, empowering the patient, family and /or caregiver to achieve maximum levels of wellness and independence.

Referring to appropriate services when applicable including but not limited to community resources and services to address the established goals or desired outcomes.

Anticipates and identifies variances in the care process related to those identified needs. Modifies plan of care to resolve unexpected care needs.

+ Leadership Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration, communication and coordination among all responsible parties of the multidisciplinary healthcare team striving to eliminate fragmentation, duplication or gaps in care.

Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provides ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly. Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.

Critical Thinking

+ Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible.

+ Monitors member's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments

+ Reports to the Care Coordination Manager or Director for Quality and Utilization regarding member status and identifies any potential risk management.

Relationships

+ Leads efforts to optimize care coordination across the care continuum, building and maintaining positive relationships with the healthcare team.

+ Assumes responsibility, authority and accountability for patient load, assisting other coworkers when requested or as the need arises.

+ Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner.

+ May also be required to meet patients and or family members either in the community, at home, or other location. Must be able to assess the environment for safety for self…