RN-Care Coordinator

Carle Health•Champaign, IL

4h•Onsite

About The Position

The Care Coordinator 3 RN is responsible for providing seamless, coordinated care across the continuum for patients identified as high risk. Responsibilities include: assessing, utilizing protocols, planning, implementing, educating/coaching, referring, coordinating/facilitating medication management, monitoring, evaluating, communicating, collaborating, and negotiating with patients, caregivers, and providers to assure the patient is receiving the right care, in the right place, at the right time.

Requirements

Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Basic Life Support (BLS) within 30 days - American Heart Association (AHA)
Certificate of Completion: Related Field
Bachelor's Degree: Nursing
Nursing experience

Responsibilities

Assists in conducting health risk assessments (HRAs) and reviews of patient records and/or claims analysis to identify care management and care coordination services
Collaborates with other Case Managers, when applicable, to ensure smooth handoffs of patients from case manager to case manager and to all involved caregivers across the continuum
Provides and manages care management and care coordination services in a timely, efficient, and cost-effective manner to meet patient-specific clinical and social needs
Assists in developing patient care plans and care goals
Monitors patient progress in relation to care plans and expected outcomes
Actively engage as an integral, collaborative member of the patient's care team
Communicates with and disseminates information to the patient, PCP, and other care team members to ensure consistent, seamless, and coordinated care
Facilitates care coordiation for the patient across the care continuum, ensuring that the patient is receiving the highest level of quality
Advocates consideration of all options available to ensure quality of care in the most cost-efficient manner
Refers patients to appropriate and available resources to meet identified needs
Supports processes to ensure that appropriate authorizations, referrals, and payor requirements are obtained and met to allow patient care
Actively involve patients/caregivers in their healthcare and encourage shared decision making.
Documents required clinical, social, financial, or other information using appropriate systems
Manages a case load of up to 100 high-risk patients
Participates in continuous quality, performance, and outcome assessment and improvement initiatives to ensure the improvement of care management/care coordination and available clinical and social support services
Assists in the development of care management tools needed to support the patient population
Provides education to patients and caregivers to optimize level of self-care
Addresses gaps in care per best practice guidelines, HEDIS measures and clinical guidelines as appropriate
Meets the patient face to face when necessary which may include: in the home, in the hospital, or in an ambulatory setting
Completes comprehensive assessment of high risk patients within the health system
Works closely with the primary care provider and interdisciplinary team to create a plan of care for each patient
Completes patient handoffs during appropriate patient transitions of care
Communicates telephonically and in person with paneled patients to ensure follow up and understanding of plan of care
Documents within EPIC using the department specific templates to ensure minimum documentation standards are met.
Participates in a committee or group outside of the department.