RN Care Coordinator

Waikiki Health•Honolulu, HI

16d•$79,160

About The Position

Founded in 1967, Waikiki Health is a nonprofit, Federally Qualified Health Center (FQHC) that offers a Patient-Centered Medical Home targeting our community’s most vulnerable populations. Our clinical and program sites provide holistic care in welcoming, supportive, and nonjudgmental environments. Waikiki Health’s mission is to provide quality medical and social services that are accessible and affordable for everyone, regardless of ability to pay. Waikiki Health is seeking a full time RN Care Coordinator The RN Care Coordinator works within a multi-disciplinary health care team in the delivery of comprehensive services for patients who are identified as high utilizers of the ED or Hospital and/or diagnosed with chronic diseases such as, but not limited, to diabetes and hypertension. The RN Care Coordinator is a patient advocate and facilitator of the Patient Centered Medical Home (PCMH) and its target population through the provision of health education, medication adherence counseling, follow-up monitoring, improvement of access to care, and guiding patients through problem focused clinical visits.

Requirements

Registered Nurse in the State of Hawaii. RN License is current, valid & in good standing
Familiarity with common software programs, (i.e. Windows-based programs) an ability to quickly learn new systems.
Ability to communicate effectively with patients, community members, and staff members.
Proficient in computer skills: typing, navigating through the internet and emails.
OSHA training.
BCLS biannually.

Responsibilities

Collaborates with medical providers and staff members to identify patients via referral from a target PCMH population who clinically demonstrate (i.e. high ER utilizer, uncontrolled hypertension) need of care coordination.
Assists health care team and patient to develop person-centered care plans tailored to patient centered needs and primary social support system.
Assesses patients for care coordination by asking and receiving consent to have care coordination, assessing disease and treatment comprehension, depression, labs, medications, and patient’s health related goals.
Complete ER/Hospital follow-up calls in a timely manner. The goal is to schedule the patient with a provider within 7 days of discharge.
Assess patient’s social determinants of health (SDOH) and provide tailored information on community resources.
Other duties as assigned.