RN Care Coordinator - Full Time

Mount Desert Island Hospital•Bar Harbor, ME

144d•Hybrid

About The Position

Versatility Are you ready to embark on a rewarding journey as an RN Care Coordinator? At our integrated care facility, we’re passionate about coordinating patient care across the entire continuum—from inpatient to outpatient to community settings. As a vital link in this chain, you’ll play a pivotal role in ensuring safe, high-quality, and cost-effective care for our patients. Navigating Transitions: You’ll orchestrate seamless transitions for patients moving from inpatient or emergency department care. Your mission? To meet their medical, rehabilitative, and financial needs with precision. Collaboration Extraordinaire: Working closely with patients, families, healthcare teams, and community resources, you’ll create a harmonious symphony of care. Goal-Driven Care: Set sail toward optimal patient function and health by establishing personalized goals based on individual needs. Your compass? The patient’s unique circumstances. Health Education Maestro: Conduct enlightening sessions on medications, disease management, and self-care. Your audience? Empowered patients ready to take charge of their well-being. Risk Whisperer: With your assessment skills and risk assessment tools, you’ll identify patients with actual or potential healthcare needs. Your mission? To ensure timely and effective care coordination. Transition Choreographer: From assessment to planning, implementation, monitoring, and evaluation, you’ll lead the dance of care coordination across all levels of transition. Versatile Performer: Whether face-to-face, in groups, or via phone, you’ll engage patients wherever they are—be it a healthcare facility, practice, office, or their own cozy home. Point-of-Care Virtuoso: When needed, you’ll wield your expertise in point-of-care testing (POCT) for diabetes management, anticoagulation therapy, and medication dosing. Education Trailblazer: If you’re an RN with the right education, you can join our Pre-diabetes (DPP) and diabetes (DSMT/DSME) education programs. Orthopedic Overture: In the orthopedic office, you’ll provide pre-op education to patients undergoing total joint replacements. Encore! Care Management Maestro: Versatility is your forte. Cross-train across all areas of care management and hit all the high notes.

Requirements

Current professional licensure as Registered Nurse in Maine.
AHA BLS certification.
3-5 years experience in acute care nursing, home health or care management.
Ability to organize, prioritize and multi-task.
Strong time management skills.
Self-motivated.
Computer proficiency.
Ability to communicate well with team, patients and family.
Experience managing those with chronic illness, behavior modification, goal setting, and education.
Valid Maine driver’s license and daily access to reliable and insured vehicle.
Must have organizational skills, the ability to self-motivate, and the ability to prioritize duties.
Proficient computer literacy including, but not limited to, electronic medical records, electronic data entry, report/data generation and retrieval.
Ability to learn multiple system software.
Ability to use Microsoft Word, Windows, Excel.
Ability to use basic office equipment: phones, computers, fax machine, scanners, copiers, calculator.
Must be able to support the organizations mission, vision, and values.
Ability to communicate clearly and effectively.
Ability to maintain effective work relationships and to work collaboratively with the health care team.
Ability to develop a collaborative therapeutic alliance with individuals.
Emotional maturity.
Critical Thinking ability.
Reading, writing, and mathematics.
Ability to analyze data and reports.
Ability to develop plans, procedures, goals, strategies or processes.
Versatility, flexibility, and willingness to work within constantly changing priorities and health care environment.

Nice To Haves

Care management experience preferred.

Responsibilities

Coordinate patient care across the continuum, from inpatient to outpatient to community settings.
Ensure safe, high-quality, and cost-effective care for patients.
Orchestrate seamless transitions for patients moving from inpatient or emergency department care.
Meet patients' medical, rehabilitative, and financial needs.
Collaborate with patients, families, healthcare teams, and community resources.
Establish personalized goals based on individual patient needs for optimal function and health.
Conduct health education sessions on medications, disease management, and self-care.
Identify patients with actual or potential healthcare needs using assessment and risk assessment tools.
Ensure timely and effective care coordination.
Manage the care coordination process from assessment to evaluation across all levels of transition.
Engage patients face-to-face, in groups, or via phone in various settings.
Perform point-of-care testing (POCT) for diabetes management, anticoagulation therapy, and medication dosing when needed.
Provide pre-op education to patients undergoing total joint replacements in the orthopedic office.
Cross-train across all areas of care management.