RN Complex Care Coordinator- Mukwonago Full Time

ProHealth Care, Inc•Waukesha, WI

2d•Hybrid

About The Position

RN Care Coordinators provide support and management for complex patients (primarily 65 and older) in the community through collaboration with ProHealth clinic providers and across the care continuum, including community resource partners. Home visits are an essential part of our care. The ideal candidate will have strong communication skills, a collaborative mindset, time management/ability to reprioritize quickly, critical and creative thinking along with a passion for 65 and older population who may have cognitive deficits in addition to other comorbidities.

Requirements

Registered Nurse (RN)
Bachelor's Degree in Nursing
5 years of hospital-based nursing experience, adult primary care clinic or home care experience required.
Basic understanding of computer use, Microsoft Outlook, internet and health information technology (Epic EHR preferred).

Nice To Haves

BSN or currently enrolled in BSN completion program preferred, but Associate's Degree in Nursing (ADN) and a Bachelor's degree in another field acceptable.
Case management, team lead or other nursing leadership experience
American Academy of Ambulatory Care Nursing: Care Coordination and Transition Management certification.
Proficient in Epic EHR, Microsoft Office suite and other health information technology.

Responsibilities

Establishes trusting relationships with patients and families/caregivers
Assists the patient in the examination, clarification and communication of their values
Assesses patient activation: the knowledge, skills and confidence they have in managing their own health and health care
Employs Motivational Interviewing to assist patients in identifying obstacles to self-management and develop patient-centered goals
Promotes healing by helping the patient and family cope with the fears and concerns that accompany life and health changes
Fosters a strong bond and facilitates partnership and communication between the patient and the primary care provider
Creates an environment that supports life-long learning that empowers patients to self-manage
Provides evidence-based patient education and assists in shared decision-making
Applies a flexible and creative approach to problem solving
Provides care coordination and collaboration during patient transitions across the Continuum of Care
Identifies barriers to disease self-management and self-care, including Social Determinants of Health
Facilitates patient access to PHC or community resources for disease-specific education, self-management and social support
Functions independently and possesses the internal discipline/drive to guide care for patients with complex health needs
Completes all EHR documentation accurately, timely and efficiently for regulatory compliance
Demonstrates effective use of healthcare and information technology resources
Attends appropriate educational opportunities and shares knowledge and experiences with others in formal and informal settings. Maximizes personal growth and develops an individual educational plan.
Demonstrates a commitment to the values of the ProHealth Experience: Respect, Relationships, Communication, Collaboration and Excellence