Registered Nurse Care Coordinator Heart and Vascular Clinic

The Nurse Care Manager works collaboratively with physicians and other members of the health care team to improve the health of patients with chronic conditions or complex needs. This position educates patients and families to help them manage their health care needs. The incumbent facilitates communication, coordinates services, addresses barriers, and promotes optimal allocation of resources while balancing clinical quality and cost management.

Monday - Friday; 8am - 5 pm (schedule negotiable)

Intermountain Heart and Vascular Clinic; 12905 West 40th, Suite 305;
Wheat ridge, CO 80401

The RN Care Coordinator position will primarily support our heart failure patients and upcoming diuresis clinic.

As an RN Care Coordinator, you need to know how to:

• Perform comprehensive assessment of patients health needs, including health status and behaviors, level of function, psychosocial situation, and available support systems and determines potential needs.
• Establish care plans in collaboration with the primary care physician and the patient care team.
• Provide health education.
• Identify patients at risk for proactive intervention.
• Pull and manipulate data to identify risk patients and present information to the care team.
• Refer patients to a variety of resources including, but not limited to: nutrition, social work, rehabilitation, behavioral specialist, diabetes education, Healthy Living Workshop, etc.
• Contact patients who utilize ED or have been hospitalized after discharge to determine the reason for the ED visit or hospitalization and work with patient to develop a plan to avoid those facilities.
• Coordinate care for complex cases or those patients seeing multiple specialists.
• Maintain up-to-date and accurate documentation of patient assessment and plan provided to the patient to ensure the effective integration of information for use by the health care team to ensure on-going and continued quality of care, in accordance with evidence-based practice.
• Analyze patient care trends and actively seek out and collaborate with the care team to improve overall quality and efficiency of care.
• Use registry data to identify problems or gaps in services and initiate intervention.
• Demonstrate critical thinking for problem solving and prioritization.
• Participate and lead patient care conferences.
• Manage patient panel with physician office staff to identify appropriate patients and measure outcomes.
• Collaborate with physicians and office staff.
• Pro-actively advocate for patient care issues to ensure that overall quality and type of care is sensitive to each specific patient/familys needs.
• Collaborate with payers and outside agencies to promote a patient centered delivery concept.
• Participate in committees and activities related to the development of Medical Home, Accountable Care Organization (ACO), and other insurance carriers.

Current RN License in state of practice.

Basic Life Support Certification (BLS) for healthcare providers.

Practice specific certification as required by the clinical setting in which they work (i.e., ACLS, PALS, etc.).

Ability to communicate effectively both verbally and in writing.

RNs with less than 12 months of working experience as an RN prior to joining Intermountain must obtain their BSN within five years of their start date.

BSN Registered Nurse with strong RN experience with heart failure or cardiology is preferred. Experience with patient education, post-discharge follow-up, medication management, care coordination, and supporting complex patients would be especially helpful.

Ongoing need for employee to see and read information, labels, assess patient needs, operate monitors, identify equipment and…