RN Patient Care Coordinator, Case Management, FT Days - Pediatric Primary Care at One Hundred Oaks

Vanderbilt University Medical Center•Nashville, TN

20h•Onsite

About The Position

Vanderbilt University Medical Center (VUMC), located in Nashville, Tennessee, is a global crossroads of teaching, discovery, and patient care. VUMC is a community where expertise is valued, knowledge expanded, and abilities challenged, committed to an environment where everyone has the chance to thrive and uniqueness is celebrated. The mission of Vanderbilt is to advance health and wellness through preeminent programs in patient care, education, and research. This RN Patient Care Coordinator position, within MCJCHV Case Mgmt, assists in developing and meeting key Pillar outcomes and system improvement goals, including financial, satisfaction, and clinical, as the nursing component of the care coordination model. The role aims to improve outcomes by reducing all-cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Responsibilities include identifying appropriate patients, encouraging patient and family engagement in self-care management, promoting warm handovers to the next level of care with timely and pertinent information, conducting patient and family education using the "teach-back" methodology, and assisting patients in navigating the healthcare system. Vanderbilt's nursing philosophy emphasizes highly skilled and specialized nursing care as essential to its mission of quality in patient care, education, and research, viewing nursing as an applied art and science focused on helping people, families, and communities achieve excellent health and well-being. Employees are encouraged to bring compassion and care to those in need of hope and healing, making a difference to patients and their families. VUMC is the largest private employer in Middle Tennessee, with over 28,000 employees across various clinical, research, and supporting roles, and operates multiple hospitals and hundreds of outpatient clinics. The organization is dedicated to personalizing the patient experience through a caring spirit and distinctive capabilities, fostering collaboration, continuous learning, and a supportive community.

Requirements

Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations.
Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums.
Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers.
Demonstrates mastery of trend analyses. Can recognize the impact and take into consideration the effect of seasonality and randomness. Has analyzed trends in detecting patterns that could lead to future problems and in forecasting future demand periods. Has worked in several areas that might include sales, marketing, quality, finance and manufacturing.
LIC-Registered Nurse - Licensure-Others
Relevant Work Experience: 5 years
Bachelor's: Nursing (Required)

Responsibilities

Coordinates the evaluation process of the defined patient population.
May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information.
Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider.
Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode.
Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population.
Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed.
Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc.
Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc.
Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence.