Health Care Home Care Coordinator

RiverView Health•Crookston, MN

1d•$37 - $51

About The Position

RiverView Health, is a community owned, membership based non-profit organization that was formed in 1898 and continues to be the sole community hospital in Crookston, MN. RiverView Health operates a 25 bed Critical Access Hospital, RiverView Recovery Center; a chemical dependency outpatient treatment program, RiverView Home Care and five primary care and specialty clinics in the hospitals service area. We have a robust scholarship program for those furthering their education in a medical field, excellent benefits, and a friendly work environment. Full-time benefits include health insurance, free single vision and basic dental insurance, life insurance, long-term disability and short-term disability, and employer HSA contributions. Other benefits include employer pension matching, shift differential, incentive/premium pay, free annual biometric screening and paid volunteer time off. RiverView is an Equal Employment Opportunity employer. Health Care Home Care Coordinator (RN) - Clinic - full-time (80 hours every 2 weeks). Schedule: Full-Time (1.0 fte) - 80 hours per pay period Scheduled Hours: Monday-Friday - 8:00am - 4:30pm Pay Range: $36.52 - $51.14 / hr (based on experience) Job Status: Non-Exempt/Hourly, benefitted position This position contributes to the efficiency and effectiveness of the clinic’s services in providing care coordination for adults, children and families which also includes access to services and skills training to people experiencing high risk and complicated physical and/or mental health issues. This position reports to the Clinic Director. Utilizing an approach that is culturally tailored and supports patients’ recovery, provide care management services for high risk patients that promote improved functioning, the development of skills and management of chronic conditions or debilitating socio-economic life circumstances. Monitor the planning for patients who have a high level of service need and who are at risk of frequent hospitalizations or ER visits and design interventions that reduce that frequency. Complete brief screenings with patients and their families to identify the level of care or services that they need such as the PHQ-9, the Ages and Stages Questionnaire for Children, and other tools. Meet the high risk patients and their family members as appropriate to develop an individual care plan. Assist the patient and their family members in developing measureable goals to achieve preventive benchmarks, reduce the incidence of inappropriate ER use or hospitalizations, and mange chronic conditions and /or debilitating life circumstances. Facilitate coordination between medical, behavioral health and dental services to promote integrated care. Assist the client in arranging crisis assessment, intervention and stabilization services. Connect the patient and their family members as appropriate to needed community resources to help them meet the goals of their plan. Coordinate the services with other agencies as needed. Follow up with other service providers to ensure that the patient is utilizing the resources. Provide routine contact and other monitoring or communicating with the patient, family members, and providers about the status of the patient, the clinic care plan or progress in achieving the goals of the care plan. Promote the Recovery Model and patient’s empowerment in their recovery process and in meeting their health care goals throughout the clinic. Provide interventions which may include home visits, skilled based training, and patient health education offered on an individual or group basis. Assess and evaluate the effectiveness of services received by the patient Completed all planning, assessing, record keeping and documentation associated with care management that meets all funding expectations and requirements Healthcare Home. Participate in clinical and administrative supervision for cases, participate in weekly team meetings, trainings, and field evaluation of care Participate in community outreach and develop partnerships that aid patients in achieving their recovery goal. Enroll patients in programs such as We Can Prevent Diabetes. Provide group education in the community with other agencies as needed around common health topics

Requirements

RN required
Two+ years experience working within a clinical care environment, including use of an electronic health record (EHR).
Ability to work effectively in a team environment.
Demonstrated ability to coordinate care across medical, behavioral health, dental, and community resources.
Ability to work with patients of all ages and backgrounds with professionalism and care.
Excellent organizational skills and attention to detail.
Strong communication and interpersonal skills.
Strong project management, analytical, and problem‑solving skills to support patient care planning and clinic process improvement.

Nice To Haves

BSN
One+ years supervisory experience.
Five years of e xperience in providing care coordination to a complex, diverse population.
Five years experience in managing clinical care using an electronic health record.

Responsibilities

Utilizing an approach that is culturally tailored and supports patients’ recovery, provide care management services for high risk patients that promote improved functioning, the development of skills and management of chronic conditions or debilitating socio-economic life circumstances.
Monitor the planning for patients who have a high level of service need and who are at risk of frequent hospitalizations or ER visits and design interventions that reduce that frequency.
Complete brief screenings with patients and their families to identify the level of care or services that they need such as the PHQ-9, the Ages and Stages Questionnaire for Children, and other tools.
Meet the high risk patients and their family members as appropriate to develop an individual care plan.
Assist the patient and their family members in developing measureable goals to achieve preventive benchmarks, reduce the incidence of inappropriate ER use or hospitalizations, and mange chronic conditions and /or debilitating life circumstances.
Facilitate coordination between medical, behavioral health and dental services to promote integrated care.
Assist the client in arranging crisis assessment, intervention and stabilization services.
Connect the patient and their family members as appropriate to needed community resources to help them meet the goals of their plan.
Coordinate the services with other agencies as needed.
Follow up with other service providers to ensure that the patient is utilizing the resources.
Provide routine contact and other monitoring or communicating with the patient, family members, and providers about the status of the patient, the clinic care plan or progress in achieving the goals of the care plan.
Promote the Recovery Model and patient’s empowerment in their recovery process and in meeting their health care goals throughout the clinic.
Provide interventions which may include home visits, skilled based training, and patient health education offered on an individual or group basis.
Assess and evaluate the effectiveness of services received by the patient
Completed all planning, assessing, record keeping and documentation associated with care management that meets all funding expectations and requirements Healthcare Home.
Participate in clinical and administrative supervision for cases, participate in weekly team meetings, trainings, and field evaluation of care
Participate in community outreach and develop partnerships that aid patients in achieving their recovery goal.
Enroll patients in programs such as We Can Prevent Diabetes.
Provide group education in the community with other agencies as needed around common health topics