RN Care Coordination

Sarah Bush Lincoln•Greenville, SC

2d•$32 - $50•Onsite

About The Position

Coordinates team based care to provide health services to individuals, families and/or their communities through effective partnerships with patients, their caregivers and their physician. Facilitates a shared goal model within an across settings to achieve coordinated high quality care that is patient/family centered.

Requirements

ADN (Required)
BLS or CPR certification (within 90 days of hire) - Sarah Bush Lincoln
RN-Registered Nurse - Illinois Department of Financial and Professional Regulation

Responsibilities

Actively participates in data collection and analysis for ACO.
Assess patient and family’s unmet health and social needs.
Attend all Care Coordination related training and meeting activities.
Coach patients/families toward successful self-management of their chronic disease.
Coordinates a strategic approach to detect early and manage effectively the patient with chronic disease. Establish an effective internal tracking system for identified patients.
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.
Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
Ensure compliance of 33 Quality Metrics through data abstraction on an ongoing basis. Provides written report of 33 Quality Metrics on a monthly basis to CNO and Providers. Monitors for trends and makes improvements with assistance of Providers as needed.
Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed.
Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator).
Oversight of Medicare Well Visit program and Chronic Care Management program.