RN Complex Care Coordinator - Transitional Care Management - Full Time

ProHealth Care, Inc•Hartland, WI

3d•Hybrid

About The Position

Care Management is seeking an RN Complex Care Coordinator to support medically complex patients across ProHealth Care’s clinic network and care continuum. This role primarily supports adults age 65+ with chronic conditions, cognitive concerns, transportation barriers and ongoing care coordination needs. This position is ideal for an RN who enjoys relationship-based care coordination, autonomy, critical thinking and helping patients navigate complex healthcare and social needs throughout the continuum of care. This position includes in home visits.

Requirements

RN experience in care coordination, ambulatory care, geriatrics, home health, transitional care or community health
Strong communication, organizational and critical thinking skills
Comfort working independently with a high level of autonomy
Passion for supporting older adult and medically complex patient populations

Nice To Haves

Epic experience preferred

Responsibilities

Coordinating care for medically complex patients across ambulatory and community settings
Supporting patient transitions throughout the continuum of care
Identifying and addressing barriers impacting self-management and healthcare access
Collaborating with providers, clinic teams, social work and community partners
Conducting telephonic outreach and home visits
Assisting patients with transportation and community resource coordination
Utilizing motivational interviewing and patient-centered care planning
Managing a dynamic caseload while reprioritizing throughout the day
Completing accurate and timely Epic documentation
Initiates, monitors and evaluates best practices for complex case management
Collaborates with physicians, advanced practice providers, and ancillary health care team members to coordinate system and community resources to maximize advocacy for patient and family care in achieving the most effective outcomes
Advocates for the patient by providing support and resources in order to reach optimal function and health, in an appropriate environment
Develops a patient-centered plan of care to optimize wellness and quality of life, operating from an in depth understanding of their unique meaning of health, illness and disease
Maintains a broad perspective of the patient’s journey across the Continuum of Care in order to assist with navigation and coordination of care
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