Care Coordinator-RN

Greater Regional Health•Creston, IA

About The Position

Greater Regional has a full-time opportunity for an RN to work as a Care Coordinator. The role coordinates team-based care by partnering with patients, caregivers, families, community resources, and physicians to provide health services. The Care Coordinator arranges support that promotes patients’ ability to provide self-care at home and facilitates referrals to outside agencies as needed. Effective communication skills and familiarity with community services are important to success in the role. The position works primarily with Med Surg, Diabetic Education, and ER care coordination needs, with cross-training in all areas. It assesses patients’ and families’ unmet health and social needs, develops and monitors care plans, supports medication management and follow-up, promotes healthy behaviors and health literacy, and coordinates community resources and services. Greater Regional describes itself as a Top 50 Workplace in Iowa for eight consecutive years and a Top 100 Critical Access Hospital for seven consecutive years. Benefits offered to full-time employees include IPERS, tuition reimbursement, wellness screenings, and wellness reimbursements. Referral-bonus eligibility is subject to the stated conditions for current employees and new hires.

Requirements

Current RN licensure.
BSN required within three years.
Three to five years of experience in clinical or community health settings.
A bachelor’s degree in social work or a bachelor’s degree in a human services field (including sociology, special education, rehabilitation counseling, or psychology) and one year of supervised social work experience in a healthcare setting working directly with individuals is an alternative qualification path.
Previous experience in Care Coordination, Case Management, or Home Health is preferred but not required.
Previous experience with health IT systems and data reports is preferred.
Experience mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations.
Effective communication skills and familiarity with community services.

Nice To Haves

Previous experience in Care Coordination, Case Management, or Home Health.
Previous experience with health IT systems and data reports.
Experience mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations.

Responsibilities

Assess patients’ and families’ unmet health and social needs and assist them in accessing resources to meet those needs.
Attend and actively participate in Care Coordination training and meetings as required by the department director.
Develop care plans based on mutual goals with the patient, family, and provider, including emergency plans, medical summaries, and ongoing action plans as appropriate.
Monitor adherence to care plans and progress toward goals, and facilitate changes as needed.
Maintain contact with family members, with the patient’s permission, regarding health changes, goals, discharge planning, and participation in care planning.
Promote healthy behaviors and help patients navigate community resources.
Assist patients in understanding test results, managing medications, and adhering to follow-up appointments.
Develop systems to prevent errors, including effective medication reconciliation and shared medical records.
Communicate effectively to improve health literacy.
Collaborate with outside organizations on legal matters as needed.
Remain current on federal and state rules and regulations, policies, and procedures.
Coordinate meetings, resources, and interviews as needed to support desired clinical outcomes within the desired timeframe.
Coordinate team-based care with patients, caregivers, families, community resources, and physicians.
Arrange support that promotes patients’ ability to provide self-care at home and facilitate referrals to outside agencies as needed.
Work primarily with Med Surg, Diabetic Education, and ER care coordination needs, and cross-train in all areas.