CARE COORDINATION, RN - FULL TIME

WATSON CLINIC LLP•Lakeland, FL

About The Position

The Care Coordination RN actively participates in managing patients with complex needs, including conducting telephonic visits for Medicare Wellness, Transitional Care Management, and Chronic Care Management. The role develops care plans, assists with managing high utilizers, and identifies barriers to care to support successful management of patients’ disease states. The RN works with care teams and patients to provide efficient, effective, and quality care to the community. The position involves coordinating patient care by phone and video, supporting access to primary care and specialist appointments, collaborating with patients and care teams, and developing and monitoring individualized care plans focused on disease management and patient empowerment. The RN documents encounters and patient discussions, completes documentation promptly, bills appropriately for services rendered, and uses technology—including Epic Healthy Planet—to support care coordination. This role has no supervisory responsibility. The work environment is fast-paced, highly productive, and may be stressful. Local travel to hospitals for patient rounding and meetings, as well as to Skilled Nursing Facilities, is required.

Requirements

Active Registered Nurse license for the State of Florida.
Two years of experience working in both inpatient and ambulatory care settings, such as a physician office, hospital, or Hospice.
Excellent listening and interpersonal skills.
Ability to maintain confidences.
Flexibility, resourcefulness, and problem-solving ability.
Ability to handle multiple tasks simultaneously and set priorities.
Basic knowledge of Microsoft Office Suite.

Nice To Haves

Proficiency with Excel.
Bachelor’s degree.
Case Management Certification.
Experience in a Primary Care Setting.

Responsibilities

Conduct telephonic and video care coordination visits, including Medicare Wellness Visits, Transitional Care Management, and Chronic Care Management.
Perform medication reconciliation, document patient-reported home vital signs, and conduct outreach supporting coding efforts and closure of quality gaps.
Help patients access primary care and specialist appointments within recommended time frames, following provider protocols and scheduling best practices.
Collaborate with patients, their families, providers, clinical staff, and outside care entities as an active member of the patient’s care team.
Develop and implement individualized, goal-driven patient care plans focused on disease management and patient empowerment.
Educate patients’ families and caregivers on carrying out care plans.
Monitor patient progress, revise care plans as needed, and provide ongoing education and support.
Document encounters and patient-related discussions, complete documentation in a timely manner, and appropriately bill for services rendered.
Use technology to support patient care, including the Epic Healthy Planet suite of products.
Travel to local hospitals for patient rounding and meetings, and to Skilled Nursing Facilities.