Care Coordinator - Temporary

Tahoe Forest Health System • Truckee, CA

2d

About The Position

The Registered Nurse Care Coordinator is responsible for coordinating care for medically complex patients, including medical care, education, internal and external referrals, and referrals to community resources. The Care Coordinator works with each patient to develop a patient-centered plan of care based on the patient’s needs and self-management goals. The role also involves active collaboration with the healthcare team and local community partners to improve patient health outcomes.

This is a temporary position. The role has no supervisory responsibilities. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Requirements

• Associate’s degree from a college or vocational school and completion of a nursing education program from an NLN-, CCNE-, or equivalent-accredited school of nursing; the program must include clinical experiences with actual patients under qualified faculty supervision.
• California Registered Nurse (RN) license upon hire.
• Nevada Registered Nurse (RN) license within 3 months of hire into the job.
• Basic Life Support (BLS) for Healthcare Providers upon hire.
• Enrollment in the Resuscitation Quality Improvement (RQI) Basic Life Support (BLS) Entry or Prep Curriculum, depending on prior BLS certification, within 3 months of hire into the job.
• Self-disciplined, energetic, passionate, and innovative.
• Collaborative team member who follows systems and protocols to achieve a common goal.
• Highly organized with well-developed oral and written communication skills.
• Demonstrated sound judgment, decision-making, and problem-solving skills.
• Ability to maintain confidentiality in accordance with practice and State and Federal regulations.
• Confidence communicating and conducting outreach with community healthcare organizations, and awareness of community resources.
• Demonstrated computer skills.
• Proficiency using an Electronic Medical Record (EMR).
• 6 months to 1 year of relevant experience.

Responsibilities

• Perform the nursing process through assessment, planning, implementation, and evaluation of safe therapeutic care, developing patient-centered plans of care for medically complex patients.
• Collaborate actively with the healthcare team as a patient advocate.
• Assist patients in navigating the healthcare system and community by coordinating their care.
• Facilitate health and disease education through individual and class teaching as indicated.
• Support patient self-management of disease and behavior modification interventions.
• Ensure home monitoring and patient knowledge are consistent with the treatment plan as indicated.
• Coordinate continuity of patient care with internal and external healthcare providers.
• Attend clinic, field, and home visits as indicated to monitor patient progress and assess needs.
• Manage high-risk patient care, including patients with multiple co-morbidities or high risk of hospital readmission.
• Promote clear communication among the care team and treating clinicians by ensuring awareness of patient care plans.
• Facilitate patient medication management based on the medication reconciliation process.
• Connect patients with community resources as indicated by Social Drivers of Health assessments.
• Participate on a team conducting data collection, health outcomes reporting, and clinical audits.
• Demonstrate System Values in performance and behavior.
• Comply with System policies and procedures.
• Perform other duties as assigned.

What This Job Offers

• Education Level: Associate degree