RN - Care Coordinator (CHF)

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RN - Care Coordinator (CHF)

Job Description

RN Care Coordinator works with SBL patients to perform timely coordination of quality healthcare services. This position is designed to assist in meeting an individual's specific healthcare needs in a cost effective manner to promote positive outcomes. The RN Care Coordinator works under the supervision of the ACO Director. This position services in an expanded nursing role to operate within applicable patients' primary care team/office and collaborate with hospital-based care coordinators, case managers, and skilled nursing facilities to provide a model of care that endures the delivery of quality, efficient, and cost-effective healthcare services.

Hours: 8am-4:30pm

Requirement: Active RN in the State of IL, ADN

Responsibilities

Assessment - Collects pertinent data and information relative to the patient's health or the situation. Recognizes normal and abnormal findings when gathering data., Cognizant of and participates in assigned site statistics, focus review, and goals and actions. Develops systems of care that monitors patients’ progress and promote early intervention in acute care situations., Collaborates with community agencies/resources to provide timely services including quality outcomes, patient and physician satisfaction, cost and service levels. Coordinates and implements referrals by communicating directly with physician, patients/families, vendors, agencies, HMOs, Medical Director, CM staff, Hospital Staff and other appropriate ancillary providers on a regular basis., Coordination of Care - Plans and evaluates care in collaboration with appropriate disciplines., Demonstrates ability to influence and negotiate individual and group decision-making through health coaching strategies. Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment., Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals. Demonstrates ability to work autonomously and be directly accountable for assigned primary care practice(s)., Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving and decision-making, priority setting, work delegation and work organization. Acts as advocate for the member as indicated and educates/coaches member regarding care needs and disease process., Diagnosis - Analyzes assessment data to determine actual or potential diagnosis, problems, issues., Evaluation - Evaluates progress toward attainment of goals and outcomes. Reports data and outcomes to others as appropriate., Identify patients with anticipated high cost care, recent hospital/ER admission requiring transition of care from hospital/SNF to home, high utilization of services, complex medical needs or those at high risk for complications or exacerbation from disease using decision support tools, inpatient/ER admissions, claims and physician referral mechanisms. Assesses patient’s clinical status in person or telephonically to determine healthcare needs., Implementation - Implements care or work plan in alignment with the plan and approved safety, infection control,and department/organization standards., Integrates evidence-based clinical guidelines, preventive guidelines, protocols, and other metrics in the development of treatment plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the population served. Manages utilization and practice metrics to further refine the delivery of care model to maximize clinical, quality, and fiscal outcomes., Knowledge - In collaboration with leaders, actively pursues required knowledge and skills through orientation activities specific to the position, reading current literature and seeking new learning opportunities., Monitors and follows up on all cases. Complies with all necessary documentation requirements to meet regulatory agency requirements. Cognizant of all other department duties and functions, such as quality, referrals, and provider relations and understands how and when to interface with those designated staff members., Outcomes Identification - Identifies expected outcomes for a plan individualized to the patient or situations., Planning - Develops a plan that prescribes strategies to attain expected, measurable outcomes., Plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status and promoting safe transitions of care. Develops individualized plan for member by discussing treatment options, identifying appropriate services required, referring to the specific ancillary providers, community programs or facilities, i.e. (Skilled/Extended Care Facility) while ensuring that those resources are being utilized in a cost effective manner in order to achieve positive outcomes., Relationships - Establishes effective working relationships with peers, physicians, and other members of the health care / work team. Identifies and confers with appropriate resources regarding patient / work decisions., Teaching - Employs teaching strategies to promote health and a safe environment., Works as extension of patient’s primary care physicians/providers and care team; communicates pertinent clinical and nonclinical patient information with physician by phone, email, practice EMR to affect appropriate clinical outcomes., Works effectively as a team member with all members of the patient’s health care team to optimize interventions. Refers members to appropriate disease management and or quality improvement or pharmacy programs (CHF, COPD, asthma, DM).

Requirements

ADN (Required)BLS or CPR certification (within 90 days of hire) - Sarah Bush Lincoln, RN-Registered Nurse - Illinois Department of Financial and Professional Regulation

Compensation

Estimated Compensation Range

$70,158.40 - $108,742.40 Pay based on experience