RN Care Coordinator- Southgate

St. Elizabeth HealthCare • Southgate, KY

75d

About The Position

The RN Care Coordinator (OCC) works collaboratively with providers, interdisciplinary staff, and clinical associates, in person and telephonically, at any/all SEP offices to support patients with chronic conditions and/or complex needs according to guidelines established by SEP and other clinical programs such as PCF etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns. A RN Care Coordinator understands and adheres to established best practice care management standards of care and coordinates care using evidence-based clinical guidelines for chronic disease management.

Requirements

• Ability to manage and prioritize multiple tasks.
• Knowledge of electronic Health Records - (EPIC)
• Knowledge of Excel, Word, Outlook and PowerPoint.
• Good organizational skills.
• Work professionally with doctors, hospital administration and management, SEP associates and the public.
• Organized, neat and self-motivated.
• Warm personality with concern for others.
• Excellent verbal and written communication skills.
• Excellent interpersonal skills.
• Ability to affect change.
• Ability to perform critical analysis.
• Self-directed.
• Work well telephonically as well as face to face.
• Can work autonomously.
• Be familiar with motivational interviewing with patients.
• Positive attitude.
• Quest for learning and excellence.

Nice To Haves

• Previous Quality Assurance experience preferred.
• Care Management Certification preferred.

Responsibilities

• Documents in chart appropriately utilizing care management documentation.
• Provides patient care through collaborating with patients, providing education and clear direction to the patient and address patient concerns regarding care.
• Identify patients with chronic disease, rising risk concerns, social, financial, or educational needs for care management services.
• Respond to provider referrals and/or identify patients who meet established criteria for care management.
• Evaluate and collaborate with patients' and families to determine readiness to change and resources for support.
• Monitor compliance with plan of care and problem solve barriers to patient self-management.
• Provide support for patient and family issues, resource needs, and answering general healthcare questions.
• Do ADL assessment and home safety assessments based on patient interview.
• Identify and place order for services such as HH when patient has identified need.
• Utilize teach back method for patients who have no medical necessity to justify home health.
• Assess need and provide basic diabetic teaching.
• Document RN Care Coordinator interventions in Epic within care management documentation.
• Refer non-nursing functions to designated resources in the region.
• Coordinate with care managers in other settings as appropriate.
• Assist providers, patients, and families with Advance Care Planning.
• Explain results from screening based on protocol and guidelines.
• Perform medication reconciliation for each patient on their panel.
• Provide ongoing management for chronic conditions, working with patients to meet healthcare goals.
• Provide education and pre-printed, SEP approved educational materials as needed.
• Work collaboratively with patients to assess needs and develop a patient education plan of care.
• Answer clinical questions related to patients' chronic health conditions.
• Provide group education for established patients.
• Refer patients appropriately when needs for mental health, pharmacy, social work, respiratory therapy etc. are identified.
• Work telephonically with patients as needed.
• Ensure complete and accurate information in the Electronic Health Record.
• Coordinate referrals to community resources.
• Forward written physician orders for treatment.
• Assess patient for additional needs, develop nursing plan of care and contact physician for order-dependent items.
• Coordinate scheduling of appointments when support is needed for a multitude of disciplines.
• Maintain adequate level of resources for care coordination.
• Ensure OSHA and HIPAA compliance.
• Assist with completion of patient requests in a timely manner.
• Timely and accurate complete charting of all patient information.
• Maintain good working relationships communications with all interdisciplinary team members.
• Work with providers, interdisciplinary staff, and office staff to identify appropriate patient population for advance care planning.
• Manage and perform home visits with patients as needed.
• Attend meetings as required.
• Provide in-office support for nursing tasks.
• Collaborative communication with office staff to be available for warm hand offs and immediate patient needs.
• Assess medication affordability and assist patients with identified needs.

Benefits

• Regular working hours of 40 per week.
• Opportunity to work collaboratively in a healthcare setting.
• Engagement in community healthcare.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Associate degree