RN Care Coordinator - Care Management - PRN

Denver Health and Hospital Authority•Denver, CO

9d•Onsite

About The Position

We are recruiting for a mission-driven RN Care Coordinator - Care Management - PRN to join our team! We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey. Our Values Respect | Belonging | Accountability | Transparency

Requirements

Associate's Degree Completion of a nursing education program that satisfied the licensing requirements of the Colorado Sate Board of Nursing for Registered Nurses Required
3 years of clinical inpatient experience Required
BLS-Basic Life Support (BLS/CPR) - AHA - American Heart Association Required
RN-Registered Nurse - DORA - Department of Regulatory Agencies Required
CCM-Certified Case Manager - ANSI - American National Standards Institute
Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment required.
Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
Evidence of leadership, creativity, integrity and initiative required.
Ability to work effectively in a team environment.
Experience with windows-based computer programs and ability to use computer for data analysis and data display required; must be able to type 35 words/minute.
EPIC experience a plus.

Nice To Haves

EPIC experience a plus.

Responsibilities

Ensures barriers are identified and escalated as needed.
Upon referral conducts an initial clinical and psychosocial screen through review of the patient’s medical record, interview with the patient/family members and discussion with the physician and other healthcare team members.
Monitors the patient’s treatment plan, medical goals and prescribes services to facilitate provision of services/referrals that are needed to meet the needs of the patient during hospitalization thus driving the clinical care process.
Coordinates any needed referrals, PT/OT, wound care, dietary, pharmacy, cardiac rehab, etc. to facilitate efficient patient flow through the hospital system.
Participates in Care Conferences and Care Rounds as required and assists with the development of care plans that will meet the patient’s current and continuing healthcare needs.
Ensures that services are appropriate for the patient’s level of care and identifies any test/procedure that could be done as an outpatient and discusses alternative with the physician.
Identifies all readmissions within 30 days and initiates a readmission risk assessment within 24 hrs of identification.
Communicates the results of the risk and transition of care screening processes to the physician(s) and other healthcare team members, including external Case Managers and community-based clinic providers, as identified.
Generates a referral to the assigned Clinical Social Worker partner for implementation and collaboration of the transition of care plan throughout the hospital stay, as needed.
Supports the development and implementation of the patient’s transition of care plan working collaboratively with the Clinical Social Work partner.
Communicates any clinical changes that would alter the transition of care plan to all healthcare team members, especially the Clinical Social Worker.
Ensures state and federal regulations/rules and insurance company requirements/processes are met.
Documents the initial transition of care screening information in the patient’s clinical record according to departmental policies and procedures.