Care Coordinator-RN

Greater Regional Health•Creston, IA

8d•Onsite

About The Position

Greater Regional has a full time opportunity for an RN to work as a Care Coordinator. This individual works to coordinate team-based care to provide health services to individuals through effective partnerships with patients, their caregivers, families, community resources, and their physician. The RN Care Coordinator will make arrangements to promote the ability of the patient to provide self-care in their home environment and facilitate referrals to outside agencies as necessary. Effective communication skills and familiarity with community services are necessary for the success of this role. This position will work primarily with Med Surg, Diabetic Education, and ER needs for care coordination but will cross train in all areas.

Requirements

Current RN license
BSN or working towards a bachelor's level education

Nice To Haves

Previous experience with Care Coordination, Case Management, or Home Health preferred but not required

Responsibilities

Assess patient and family’s unmet health and social needs and provide assistance to resources to meet these needs.
Attend and actively participate in all Care Coordination related training and meeting activities as required by department director.
Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate for chronic care and traditional care management patients.
Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
Maintain contact with family (with patient’s permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning.
Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
Provide patient assistance and understanding of test results, medication management, and adherence to follow-up appointments.
Develop systems to prevent errors (e.g., effective medication reconciliation and shared medical records).
Provide effective communications to improve health literacy.
Collaborate with outside organizations on implementing or maintaining legal matters as needed.
Remain current on Federal and State rules and regulations and policy and procedures.
Mobilizes meetings, resources, and interviews, as needed, to achieve expected goal to assist in achieving desired clinical outcomes within the desired timeframe.