Care Coordinator-RN

Position Purpose

This position provides face to face, virtual or telephonic care. Collaborates with their team members both clinical and non-clinical. Coordinates services provided for patients with chronic, or behavioral health/chemical dependency needs across the lifespan to improve the quality of care and satisfaction. Identifies social determinants of health and clinical symptomology needing intervention and works within the framework of the IDT to build a longitudinal plan of care and satisfy goals.

Nature and Scope

This position shall coordinate all components of Care Coordination services to provide for individual patients’ health care needs thorough the continuum of care. This includes Care Coordination which involves deliberately organizing patient care activities and sharing information among all the participants concerned with a patients care to achieve safer, and more effective care. This means patients’ needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.

The Care Coordinator will follow the Renown policies and procedures. The Care Coordinator will follow the Care Coordination Model of Care and Standard work as defined by CMSA.

The scope includes potential for cross training within the department Care Coordination roles to cover for departmental vacations, illness and vacancies.

Position will be responsible for the following:

1. Strong interpersonal communication skills both verbal and written.

2. Remains productive and offers help and support to team members.

3. Collaborate with the patient, family, providers and team members to develop a patient centered Plan of Care and support patient with self-management goals.

4. Coordinates alternative community resources to include Home Health Care, REMSA, Durable Medical Equipment, Social Determinants and Community Partners to promote and assist the patient to have a safe environment of their choice and in alignment with the patient.

5. Facilitate, problem solve with patients, families, providers and other health care professionals to effectively resolve patient care issues.

6. Understands how to navigate Care Coordination process of Assessment, Planning, Goal Setting, Intervention, and Evaluation with the ability to utilize these components to provide for the individual health care needs and promote positive outcomes (quality).

7. Helps with transitions of care and organizes medical information.

8. Knowledge of applicable regulatory requirements and community resources

9. Knowledge of continuous quality improvement process.

10. Philosophy consistent with the corporate culture of Renown Health

11. Initiates, updates and revises: Assessments, Patient Outreach Encounter documentation and Longitudinal Plan of Care within the Health Planet module in Epic

12. Ability to document in the MIDAS system any grievances, complaints, or compliments identified.

May be responsible for other duties as assigned.

This position may be patient facing, in person, e-visits, home visit, virtual or telephonic.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred