RN Care Coordinator Ambulatory Transitions of Care

Corewell Health • Southfield, MI

13d • Hybrid

About The Position

Care Coordinator Ambulatory Transitions of Care Scope of Work: Provides care management and care coordination for patients following an acute care hospitalization. Uses evidence-based interventions and defined workflows to support successful transitions of care. Responsibilities include collaboration with members of the health care team to ensure the delivery of quality, efficient, patient center and cost-effective healthcare services. The role includes a required three to six month orientation period at the Corewell Health Southfield Center, followed by a transition to a work-from-home arrangement with occasional time in the office as required. Using a variety of methods and tools, identifies targeted high-risk population and chronically ill population within practice sites. Assesses the healthcare, educational, and psychosocial needs of the patient/family. Uses appropriate assessment tools such as depression screening, functionality, and health risk assessment. Collaborates with Primary Care Physician, patient, and members of the health care team, to assess, develop and implement an agreed upon plan of care. Participates in continuous quality improvement to enhance care management in the office setting. Monitors patient/family response to plan of care and revises the care plan as indicated. Provides self-management support with a focus on empowering the patient/family to build capacity for self- care. Ensure support for advanced directives and advanced care planning. Conducts comprehensive assessments to identify the member’s needs, self-management goals, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk or barriers that may impact the patient’s adherence to the care management plan. Using evidence-based guidelines and clinical tools, identifies patients with chronic conditions, and gaps in clinical care. Implements systems to ensure necessary care is completed and monitors individual patient progress and population health. Coordinates patient care by linking patients to resources. Provides follow up with patient/family when patient transitions from one setting to another. Completes post hospital discharge calls including medication reconciliation, coordinates physician follow-up appointments, symptoms assessment and patient education/ discharge instructions, and problem-solves barriers to compliance. Maintains required documentation for all care management activities. Works with practice and Physician Organization/Accountable Care Organization leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home delivery model and meet value-based reimbursement payer program requirements. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice. Provides education on management of chronic conditions and enhances the member’s self-efficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change. Coordinate care transitions and monitoring of high-risk members following hospital and sub-acute discharges to ensure timely follow-up with primary care and prevent readmissions.

Requirements

• Associate's Degree or equivalent Graduate of an accredited school of nursing.
• Minimum two years’ RN experience in a clinical care setting.
• Three to five years’ experience in care management, home care and/or discharge planning.
• Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire required
• At least one License and/or Certification in area of specialty - UNKNOWN Unknown Care Management Upon Hire required

Nice To Haves

• Bachelor's Degree of Science in Nursing.
• Experience in an ambulatory practice setting.

Responsibilities

• Provides care management and care coordination for patients following an acute care hospitalization.
• Uses evidence-based interventions and defined workflows to support successful transitions of care.
• Responsibilities include collaboration with members of the health care team to ensure the delivery of quality, efficient, patient center and cost-effective healthcare services.
• Identifies targeted high-risk population and chronically ill population within practice sites.
• Assesses the healthcare, educational, and psychosocial needs of the patient/family.
• Collaborates with Primary Care Physician, patient, and members of the health care team, to assess, develop and implement an agreed upon plan of care.
• Participates in continuous quality improvement to enhance care management in the office setting.
• Monitors patient/family response to plan of care and revises the care plan as indicated.
• Provides self-management support with a focus on empowering the patient/family to build capacity for self- care.
• Ensure support for advanced directives and advanced care planning.
• Conducts comprehensive assessments to identify the member’s needs, self-management goals, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk or barriers that may impact the patient’s adherence to the care management plan.
• Using evidence-based guidelines and clinical tools, identifies patients with chronic conditions, and gaps in clinical care.
• Implements systems to ensure necessary care is completed and monitors individual patient progress and population health.
• Coordinates patient care by linking patients to resources.
• Provides follow up with patient/family when patient transitions from one setting to another.
• Completes post hospital discharge calls including medication reconciliation, coordinates physician follow-up appointments, symptoms assessment and patient education/ discharge instructions, and problem-solves barriers to compliance.
• Maintains required documentation for all care management activities.
• Works with practice and Physician Organization/Accountable Care Organization leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home delivery model and meet value-based reimbursement payer program requirements.
• Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.
• Provides education on management of chronic conditions and enhances the member’s self-efficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change.
• Coordinate care transitions and monitoring of high-risk members following hospital and sub-acute discharges to ensure timely follow-up with primary care and prevent readmissions.

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree