Care Coordinator Rmg Rn

The RN Care Coordinator provides personalized care coordination services to meet the healthcare and social service needs of patients, particularly those with chronic conditions. By employing evidence-based care management strategies, the RN Care Coordinator collaborates with healthcare teams, patients, and families to bridge gaps in care and optimize health outcomes. Demonstrates flexibility with assignments within professional scope/duties/licensure.

• Care Coordination & Transition Management:
  • Provide comprehensive care coordination for patients transitioning from hospital to home or other care settings.
  • Facilitate care coordination across the continuum of care, ensuring patients receive high-quality, appropriate care at all stages.
  • Conduct telephonic health risk assessments and welcome calls to assess patient needs and obtain risk stratification information.
• Patient Assessment & Care Planning:
  • Develop individualized care plans in collaboration with patients and their families through a comprehensive bio-psychosocial assessment.
  • Employ motivational interviewing techniques to encourage patient engagement in health management and shared decision-making.
  • Monitor patient progress and adjust care plans as needed, based on ongoing assessment and patient feedback.
• Communication &
  
  Collaboration:
  • Serve as a key communicator between healthcare providers, patients, and families to coordinate and optimize care.
  • Facilitate the authorization and referral process for needed healthcare services and ensure timely delivery of care.
  • Communicate effectively with the entire healthcare team to address any gaps in care and provide updates on patient status.
• Data & Documentation:
  • Maintain accurate and timely documentation of all patient interactions, care plans, and outcomes.
  • Utilize case management software, population registries, and electronic health records (EHR) to track and monitor patient care.
  • Review available claims and risk-level information to identify patients in need of care management and coordination services.
• Quality Improvement & Program Development:
  • Participate in continuous quality improvement initiatives to enhance care management and coordination practices.
  • Assist in the development of care management tools, workflows, and best practices to support care for Riverside Healthcare patients.
• Patient & Family Support:
  • Provide education and support to patients and families regarding chronic condition management, healthcare navigation, and social service resources.
  • Reassess patient needs and barriers, adjusting care coordination plans as needed to address changes in the patient's condition or circumstances.

• Assist with special projects or tasks as assigned by the Care Coordination Director.
• Participate in ongoing training and professional development to maintain knowledge of best practices in care coordination.
• Collaborate on community outreach and education programs as needed.

• Minimum of 3 years of clinical nursing experience with a diverse patient population (including those with chronic conditions, various ages, and cultural backgrounds) OR 1 year of nursing experience and 5 years in a related healthcare field.
• Relevant clinical experience and understanding of population health management, chronic disease management, and evidence-based care coordination.
• Proficiency in Microsoft Word and Excel; familiarity with case management software and electronic health records preferred.

• Graduate of an approved school of nursing;
  Bachelor's Degree preferred.
• Current Illinois State License as a Registered Nurse (RN) required.
• * New Graduate RNs starting on or after 1/1/25 must earn Bachelors of Science in Nursing (BSN) within 3 years of…