Care Coordinator Rn

Description

The Care Coordinator works in collaboration & continuous partnership with chronically ill or “high-risk” patients & their families, clinic/hospital providers & staff, and 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.

Physician's Center - Primary Care

80 hours per pay period – benefit eligible

• 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.

• 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.