RN Care Coordinator

CommonSpirit Health•Rancho Cordova, CA

8d•Hybrid

About The Position

Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health – one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today, Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers, we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. Our 130+ clinics across the state of California deliver high-quality, patient-centric care with an emphasis on humankindness. Through affiliations with Dignity Health hospitals, along with our joint ventures and partnerships, we offer a robust, state-of-the-art health care delivery system in the communities we serve .We strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled, qualities that are vital to maintaining excellence in care and service. One Community. One Mission. One California Job Summary and Responsibilities As our RN Care Coordinator, you will coordinate care and collaborate with multiple disciplinary team members across the continuum of care to improve the quality of care and clinical outcomes for members with complex care needs. Every day you will conduct thorough assessments to determine unmet needs and develop individualized care plans, evaluate and identify knowledge gaps in disease process and treatments, determine appropriate resources or services required to meet an individual's health needs, and provide education/coaching on disease self-management for health promotion and maintenance. You will promote quality cost-effective outcomes with the goal of improved care coordination amongst providers and increased involvement of the individual family and/or caregiver in the decision making process to reduce hospitalizations, readmissions and ER visits. You will conduct both telephonic case management and direct patient contact through follow-up at clinic appointments and/or home visits, as needed. To be successful in this role, you must show compassion, use your critical thinking skills, and remember that each patient requires a custom care plan tailored to their needs. Your talent for creative thinking is vital to your success in care coordination and it will shine as you develop enhanced care plans, yielding optimal outcomes for each patient. This position is hybrid in-office/clinic (Midtown Sacramento clinic) and work from home. Concurrently reviews patient's records to collect data to carefully understand the needs of the patient by scrutinizing their background history, understanding their current needs, and arranging for their wellbeing. Coordinates with other disciplines to facilitate the patient's individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs. Assists in development, implementation and revision of individual care plans; assures that services provided are specified in the Care Plan and monitors progress toward goals, including documentation of daily improvement in patient's condition or otherwise notes lack of improvement for reassessment of appropriateness of care plan. When barriers are identified, assists the patient and the family/caregiver in developing, documenting and implementing appropriate care plans to access agencies, resources and care providers. Teach, coach and educate the patient, family and/or caregiver about their disease process to recognize signs and symptoms of worsening disease and how to take appropriate measures. Documents patient, family or caregiver's knowledge regarding medical condition(s), and indicates when condition is worsening and develop a plan for how to respond.

Requirements

Two (2) years clinical experience as a RN in acute, ambulatory care, home health, skilled nursing facility, medical group, or health plan setting required.
A Masters Degree in nursing with a concentration in Case Management can serve as a substitute for the experience requirement.
Current CA Registered Nurse (RN) license
Excellent customer service and presentation skills are a must
Strong interpersonal and written communication skills are essential
Demonstrated ability to apply analytical and problem solving skills
Ability to demonstrate leadership skills to delegate and provide direction/guidance to multidisciplinary teams
Demonstrated ability to manage multiple tasks or projects effectively
Ability to work independently as needed 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 (URAC NCQA) and complex case management (CMSM)
Knowledge of community resources
Knowledge of capitation/HMO insurance payers and government healthcare plans and audit

Nice To Haves

Prior Care Coordination experience in a clinical or insurance setting is required. If operational conditions permit training a candidate without the required experience may be considered.
BSN degree or experience equivalent preferred
Case Management (CM) certification preferred

Responsibilities

Coordinate care and collaborate with multiple disciplinary team members across the continuum of care to improve the quality of care and clinical outcomes for members with complex care needs.
Conduct thorough assessments to determine unmet needs and develop individualized care plans.
Evaluate and identify knowledge gaps in disease process and treatments.
Determine appropriate resources or services required to meet an individual's health needs.
Provide education/coaching on disease self-management for health promotion and maintenance.
Promote quality cost-effective outcomes with the goal of improved care coordination amongst providers and increased involvement of the individual family and/or caregiver in the decision making process to reduce hospitalizations, readmissions and ER visits.
Conduct both telephonic case management and direct patient contact through follow-up at clinic appointments and/or home visits, as needed.
Review patient's records to collect data to carefully understand the needs of the patient by scrutinizing their background history, understanding their current needs, and arranging for their wellbeing.
Coordinate with other disciplines to facilitate the patient's individual needs.
Make plans to resolve unexpected care requirements.
Anticipate and identify variances in the care process related to those identified needs.
Assist in development, implementation and revision of individual care plans; assure that services provided are specified in the Care Plan and monitor progress toward goals, including documentation of daily improvement in patient's condition or otherwise note lack of improvement for reassessment of appropriateness of care plan.
When barriers are identified, assist the patient and the family/caregiver in developing, documenting and implementing appropriate care plans to access agencies, resources and care providers.
Teach, coach and educate the patient, family and/or caregiver about their disease process to recognize signs and symptoms of worsening disease and how to take appropriate measures.
Document patient, family or caregiver's knowledge regarding medical condition(s), and indicate when condition is worsening and develop a plan for how to respond.