Care Coordinator, RN

The RN Care Coordinator at TRIARQ Health is central to the patient experience, connecting patients with the right providers and resources while ensuring clear, consistent communication throughout the patients’ care journey. This position requires development and maintenance of successful relationships with hospital case managers, discharge planners, home health/skilled nursing administrators, physicians and key healthcare decision makers. This position requires collaboration with all stakeholders to develop and improve care planning and care management processes across our network of partner practices and preferred providers.

This position requires collaboration with a multi-disciplinary team to provide patient education, communication with health care providers, and coordination with the facilitation of services within an episode of care. The RN Care Coordinator will have the opportunity to make a difference in reducing health care costs and increase the value of health care to patients and payers.

The RN Care Coordinator at TRIARQ Health is central to the patient experience, connecting patients with the right providers and resources while ensuring clear, consistent communication throughout the patients’ care journey. This position requires development and maintenance of successful relationships with hospital case managers, discharge planners, home health/skilled nursing administrators, physicians and key healthcare decision makers. This position requires collaboration with all stakeholders to develop and improve care planning and care management processes across our network of partner practices and preferred providers.

This position requires collaboration with a multi-disciplinary team to provide patient education, communication with health care providers, and coordination with the facilitation of services within an episode of care. The RN Care Coordinator will have the opportunity to make a difference in reducing health care costs and increase the value of health care to patients and payers.

• Coordinate and support patients following surgery and/or following diagnosis of certain conditions, delivered in partnership with participating physicians and aligned with physician-directed care plans (Medicare Advantage, BPCI, Urology Trend and MSK Trend Surgical programs).
• Provide general education, care navigation, and advocacy support, including helping BCBSM members understand available care options the member should discuss with their provider, and connecting patients to appropriate providers or resources to obtain the clinical evaluation or assistance they need (MSK Trend Non-surgical program).
• Provide support to care coordinators and clinical teams embedded within our clinically integrated network and partnered orthopedic and urological practices.
• Provide professional nursing insight to the patient throughout the continuum of care, including pre-operative and postoperative therapy, SNF, and Home Care Services.
• Create and promote adherence to a care plan, developed in coordination with the patient, physician, and family/caregiver(s).
• Engage in ongoing evaluation and revision of plan of care as determined by patient's health status.
• Communicate changes to all providers and multi-disciplinary care team members involved in the patient's care.
• Utilize the care management and referral platform (QPathways) to document patient interactions, track care coordination activities, and support continuity of care.
• Collaborate effectively with the patient’s health care team (physicians, nurses, discharge planners, referral coordinators, surgical schedulers, etc.) to establish an optimal transition plan to the most appropriate PAC (post-acute…