Care Coordinator - Temporary

Tahoe Forest Health System•Truckee, CA

13d

About The Position

The Registered Nurse Care Coordinator is responsible for the overall care coordination of 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 specific to their needs and self-management goals. Additionally, the Care Coordinator actively collaborates with the diverse healthcare team and local community partners to improve patient health outcomes.

Requirements

Associate's Degree Degree from college or vocational school from a National League of Nursing (NLN), Commission on Collegiate Nursing Education (CCNE) or equivalent accredited school of nursing. The nurse shall have completed a nursing education program that included clinical experiences with actual patients under the supervision of qualified faculty.
California Registered Nurse (RN) Upon hire
Nevada Registered Nurse (RN) Within 3 months of hire into job
Basic Life Support (BLS) for Healthcare Providers Upon hire
BLS: Employee will be enrolled in the Resuscitation Quality Improvement (RQI) Basic Life Support (BLS) Entry or Prep Curriculum (depending on their previous BLS certification). Within 3 months of hire into job
Self-disciplined, energetic, passionate, and innovative
Collaborative team member that follows systems and protocols to achieve a common goal
Highly organized and well-developed oral and written communication skills
Demonstrates sound judgment, decision-making and problem-solving skills
Ability to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations
Confidence to communicate and outreach to other community health care organizations and is aware of community resources
Demonstrated computer skills
Proficiency using Electronic Medical Record (EMR) and 6 months to 1 year relevant experience

Responsibilities

Performs the nursing process through assessment, planning, implementation and evaluation of safe therapeutic care to develop patient-entered plan of care to medically complex patients.
Actively collaborates with healthcare team as an advocate.
Assists patients through the healthcare system and community by acting as a patient care coordinator.
Facilitates health and disease patient education through individual teaching and class teaching as indicated.
Supports patient self-management of disease and behavior modification interventions.
Assures home monitoring and patient knowledge that is consistent with treatment plan as indicated.
Coordinates continuity of patient care with internal and external healthcare providers.
Attends clinic visits, field visits and home visits as indicated to monitor patient progress and assess needs.
Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
Facilitates patient medication management based upon medication reconciliation process.
Connects to community resources as indicated per Social Drivers of Health assessment.
Participates on a team for data collection, health outcomes reporting, and clinical audits.
Demonstrates System Values in performance and behavior.
Complies with System policies and procedures.
Other duties may be assigned.