RN Care Coordinator

Dignity Health Medical Foundation•Rancho Cordova, CA

1d•$55 - $81•Remote

About The Position

The RN Care Coordinator coordinates care and collaborates with multidisciplinary team members across the continuum of care to improve care quality and clinical outcomes for members with complex care needs. The role conducts thorough assessments to identify unmet needs, develops individualized care plans, evaluates knowledge gaps related to disease processes and treatments, identifies appropriate resources and services, and provides education and coaching on disease self-management. The goal is to promote quality, cost-effective outcomes, improve coordination among providers, increase patient and family or caregiver involvement in decisions, and reduce hospitalizations, readmissions, and emergency department visits. The position includes telephonic case management and direct patient contact through follow-up at clinic appointments and, as needed, home visits. The coordinator supports development, implementation, and revision of individual care plans; monitors progress and documents improvement or lack of improvement; and helps patients and caregivers address barriers by connecting them with agencies, resources, and care providers. The coordinator teaches patients and caregivers to recognize worsening symptoms and respond appropriately, supports medical management plans established by primary and specialty providers, promotes self-management and independence, and helps patients navigate the healthcare system and maintain necessary appointments. This is a work-from-home position for California residents. Equipment provided includes a laptop, docking station, dual monitors, and accessories. The position is non-benefitted and on-call.

Requirements

Two years of clinical RN experience in acute care, ambulatory care, home health, a skilled nursing facility, a medical group, or a health plan setting; a master's degree in nursing with a concentration in Case Management may substitute for the experience requirement.
Current California Registered Nurse (RN) license.
Excellent customer service and presentation skills.
Strong interpersonal and written communication skills.
Ability to apply analytical and problem-solving skills.
Ability to demonstrate leadership by delegating and providing direction or guidance to multidisciplinary teams.
Ability to manage multiple tasks or projects effectively.
Ability to work independently with a high degree of detail orientation.
Ability to work efficiently in a fast-paced environment with changing priorities.
Knowledge of regulatory and accreditation standards, including URAC and NCQA, and complex case management (CMSA).
Knowledge of community resources.
Knowledge of capitation/HMO insurance payers, government healthcare plans, and audit.

Nice To Haves

Prior care coordination experience in a clinical or insurance setting; the posting notes that a candidate without the required experience may be considered if operational conditions permit training.
BSN degree or equivalent experience.
Case Management (CM) certification.

Responsibilities

Coordinate care and collaborate with multidisciplinary team members across the continuum of care for members with complex care needs.
Conduct assessments to identify unmet needs and develop individualized care plans.
Evaluate and identify knowledge gaps relating to disease processes and treatments.
Determine appropriate resources and services to meet individuals' health needs.
Educate and coach patients, families, and caregivers on disease self-management, health promotion, and maintenance.
Promote quality, cost-effective outcomes, provider coordination, and patient and caregiver involvement in decision-making, with the aim of reducing hospitalizations, readmissions, and emergency department visits.
Conduct telephonic case management and direct patient follow-up at clinic appointments or through home visits as needed.
Assist with developing, implementing, and revising care plans; ensure services align with the plan and monitor and document progress toward goals.
Help patients and caregivers address barriers by developing, documenting, and implementing plans to access agencies, resources, and care providers.
Teach patients, families, and caregivers to recognize signs and symptoms of worsening disease and take appropriate action.
Document patient and caregiver knowledge of medical conditions and develop a response plan for worsening conditions.
Support medical management plans established by primary and specialty providers and educate patients about established treatment options.
Promote patient self-management, problem-solving, wellness, and independence.
Help patients navigate the healthcare system to reduce fragmented services and obtain timely care, provider access, services, and procedures.
Monitor adherence to PCP and specialist appointments, identify patterns of nonadherence, and coordinate needed appointments.