RN Care Coordinator; Float- out of Independence Primary Care​/to float to KY offices

Job Summary

Reports to the RN Manager of Care Coordination, the RN Care Coordinator (Float) works collaboratively with providers, interdisciplinary staff, and clinical associates, in person and telephonically, at any/all SEP offices to support patients with chronic conditions and/or complex needs according to guidelines established by SEP and other clinical programs such as PCF etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns.

A RN Care Coordinator Float role requires travel to any/all SEP offices per manager discretion.

Regular

40

Reports to the RN Manager of Care Coordination, the RN Care Coordinator (Float) works collaboratively with providers, interdisciplinary staff, and clinical associates, in person and telephonically, at any/all SEP offices to support patients with chronic conditions and/or complex needs according to guidelines established by SEP and other clinical programs such as PCF etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns.

A RN Care Coordinator Float role requires travel to any/all SEP offices per manager discretion.

A RN Care Coordinator
- Float works primarily in the ambulatory setting and is a member of the physician led interdisciplinary team. A RN Care Coordinator
- Float understands and adheres to established best practice care management standards of care. A RN Care Coordinator
- Float understands and coordinates care using evidence based clinical guidelines for chronic disease management.

Job Title: SEP - RN Care Coordinator (Float)
- Home base out of Independence Primary Care/Required to float to other KY offices as needed

• Degree in nursing (ADN or higher)
• REQUIRED:
  
  Current Driver’s License in good standing and reliable and insured transportation

• Kentucky Registered Nurse (RN) Compact License (or any RN compact license) required.
• Care Management Certification preferred.

• Minimum of 3 years nursing experience or current care management position held within SEP Clinical Transformation.
• Demonstrated knowledge of anatomy and physiology, pharmacology, etc.
• Ambulatory and/or care management experience.

Previous Quality Assurance experience preferred.

• Documents in chart appropriately utilizing care management documentation.
• Provides patient care through collaborating with patients, providing education and clear direction to the patient and address patient concerns regarding care. The RN engages in critical thinking to meet patient needs.
• Support Chronic Disease Management and Patient Care Needs:
• Identify patients with chronic disease, rising risk concerns, social, financial, or educational needs for care management services.
• Respond to provider referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or blood pressure, Mental Health Integration referral, complex needs)
• Evaluate and collaborate with patients’ and families to determine readiness to change and resources for support.
• Monitor compliance with plan of care and problem solve barriers to patient self-management.
• Provide support for patient and family issues, resource needs, and answering general healthcare questions.
• Do ADL assessment and home safety assessments based on patient interview.
• Identify and place order for services such as HH when patient has identified need
• Utilize teach back method for pts who have no medical necessity to justify home health.
• Assess need…