Continuing Care RN Coordinator

Dignity Health Management Services•Bakersfield, CA

1d•$55 - $81•Remote

About The Position

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first. One Community. One Mission. One California Job Summary and Responsibilities As our Continuing Care RN Coordinator, you will be a central figure in patient care, seamlessly navigating the healthcare journey to achieve optimal outcomes and an exceptional patient experience. Every day, you will strategically assess, plan, and facilitate comprehensive care across the continuum, expertly advocating for patients while collaborating with physicians, nursing, departments, insurers, and post-acute providers to ensure timely, high-quality transitions. To be successful in this role, you will possess strong clinical acumen, exceptional communication and advocacy skills, and a strategic mindset, all driven by a passion for optimizing patient care across every touchpoint. As a remote employee, we will provide you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories. This position is work from home for residents of CA. Future potential for occasional weekend/holiday coverage. Works with “at risk” patients and families on self-management support, including collaborating with patients to create a plan of care for health behavior change. Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration, communication and coordination among all responsible parties of the multidisciplinary healthcare team striving to eliminate fragmentation, duplication or gaps in care. Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provides ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly. Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc. Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible. May also be required to meet patients and or family members either in the community, at home, or other location. Must be able to assess the environment for safety for self and patients and escalate any concerns to the Medical Social Worker, Licensed Social Worker or program manager based on the situation.

Requirements

Two (2) years relevant experience or advanced degree
Associates degree in Nursing
Clear and current CA Registered Nurse (RN) license
Excellent computer skills and ability to learn new systems
Strong organizational (time management) and interpersonal skills
Ability to handle multiple priorities with strong attention to detail
Ability to communicate effectively using written and verbal skills.
Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word.
Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost)
Ability to work autonomously within a matrix environment without direct supervision or support

Nice To Haves

Bachelors of Nursing (BSN) preferred
5+ years of care coordination experience preferred
Experience with telephonic care coordination preferred
Experience with motivational interviewing and effective telephonic engagement with patients preferred
Bi-lingual preferred

Responsibilities

Strategically assess, plan, and facilitate comprehensive care across the continuum.
Expertly advocate for patients while collaborating with physicians, nursing, departments, insurers, and post-acute providers to ensure timely, high-quality transitions.
Work with “at risk” patients and families on self-management support, including collaborating with patients to create a plan of care for health behavior change.
Lead an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration, communication and coordination among all responsible parties of the multidisciplinary healthcare team striving to eliminate fragmentation, duplication or gaps in care.
Design plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provide ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly.
Work toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.
Assist patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible.
May be required to meet patients and or family members either in the community, at home, or other location.
Assess the environment for safety for self and patients and escalate any concerns to the Medical Social Worker, Licensed Social Worker or program manager based on the situation.
Manage and work closely with interdisciplinary partners in the management of identified patient populations.
Oversee a mix of clinical, operational, and business activities related to that team.
Implement specific program goals including high priority case management redesign efforts required to improve performance.
Work closely with and in partnership with Community resource partners, Post Acute Care Providers, Acute Care Coordinators and other clinical staff who are focused on care coordination in order to ensure that patients' care and transition of care from acute care to post-acute and ambulatory care are seamless.
Assess, report, and communicate patient status on a periodic basis to all team stakeholders.