RN - Registered Nurse - Care Coordinator - Lebanon, IN

External job board Witham Careers•Lebanon, IN

6d•Onsite

About The Position

The Care Coordinator RN role at Witham Health Services in Lebanon, IN, focuses on coordinating team-based care to provide health services to individuals, families, and communities. This position involves building effective partnerships with patients, their caregivers, and their physicians to facilitate a shared goal model across different settings, ultimately achieving coordinated, high-quality, patient/family-centered care.

Requirements

Graduate from an accredited school of nursing program; BSN preferred.
Valid license to practice Nursing in the State of Indiana.
3-5 years' experience in clinical or community health settings.
Demonstrates evidence of essential leadership, communication, education, and counseling skills.
Proficient in communication technologies (email, cell phone, etc.).
Effective organizational skills, demonstrates ability to maintain accurate notes and records.
Core values consistent with a patient/family centered approach to care.
Demonstrates professional, appropriate, effective written, verbal and nonverbal communication skills.
Demonstrates a positive attitude and respectful, professional customer service.
Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
Proactively acts as patient advocate, responding with empathy and respect to resolve patient/family concerns.
Recognizes opportunities for improvement to meeting patient concerns.
Demonstrates continual learning skills, effects changes in approach to care based on established evidence based practice.
Demonstrates professional practice behavior, provides mentoring/coaching of other population health/care coordination team members.
Cultivates effective partnerships and collaboration with physician providers.
Demonstrates understanding of use of I.T. resources and patient databases to promote successful/appropriate provider encounters.
Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.

Nice To Haves

BSN preferred.
Previous Care Coordination and/or Case Management experience preferred.
Previous experience with health IT systems and data reports preferred.
Previous experience with mobilizing community resources, navigating through the healthcare continuum and working with disparate populations preferred.
Ability to speak Spanish as a second language preferred.

Responsibilities

Provide a coordinated strategic approach to detect early and manage effectively the patient with chronic disease.
Establish an effective internal tracking system for identified patients.
Coach patients/families toward successful self-management of their chronic disease.
Utilizing tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
Assess patient and family's unmet health and social needs.
Provide effective communications to improve health literacy.
Develop a care plan based on mutual goals with the patient, family, and providers (emergency plan, medical summary, and ongoing action plan, as appropriate).
Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely way, and facilitate changes as needed.
Create ongoing processes for patients and families to determine and request the level of care coordination support they desire at any given point in time.
Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator).
Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
Develop systems to prevent errors (e.g. effective medication reconciliation and shared medical records).
Facilitate and attend meetings between patient, family, care team, payers, and community resources, as needed.
Attend all Care Coordination related training and meeting activities.
Provide feedback for the improvement of the Care Coordination Program.
All other duties as assigned.