RN Care Coordinator

RN Care Coordinator # This innovative position places the registered nurse (RN) in a Care Coordinator role partnering with primary care providers.# The majority of our primary care practices are certified Patient-Centered Medical Homes (PCMH).# The Medical Home Care Coordinator is a vital part of the multidisciplinary healthcare team which strives to coordinate care and optimize outcomes for patients and our healthcare system.# # Care Transition Coaching and Coordination

Reduce unnecessary hospitalizations and re

-hospitalizations by working with patients who were discharged from various healthcare facilities.# Work with the primary care team to ensure follow-up visits are scheduled within 48 hours of facility discharge.

Use Motivational Interviewing and coaching strategies to help patients identify and meet their healthcare goals

.

Develop individualized care plans to help patients track and meet their goals

.

Provide care coordination strategies via telephonic support and

/or face-to-face to engage and educate patients.

Develop and promote constructive relationships with inpatient, outpatient and community personnel to meet patient needs and goals. ###

Guide process and performance improvement initiatives in the primary care setting to meet strategic goals.# ###

Engage with home care agencies, specialists, and any other integral providers or resources in case management activities. Population Management ###

Prioritize high risk patient needs with physicians, office staff, and the health care team. ###

Leverage clinical informatics to identify high risk, high need, and potentially high cost patients of the medical home to manage their care.# ###

Utilize electronic medical record (EMR) and chronic disease registry reporting to prioritize patient outreach.# ###

Coordinate with Case Management and Disease Management staff when applicable # Qualifications Education/Experience: ###

RN licensure required.# #BSN preferred. ###

Certified Case Management (CCM) preferred ###

Five to eight years of direct patient care experience required ###

Must have experience with Microsoft Office (Word, Excel, PowerPoint).# ###

Must possess the ability to quickly learn new IT systems and software.# ###

Must be able to adjust and prioritize tasks in a dynamic environment. ###

Experience with an EMR strongly preferred ###

Experience analyzing, sorting and drawing conclusions from data strongly preferred. #

RN Care Coordinator

This innovative position places the registered nurse (RN) in a Care Coordinator role partnering with primary care providers. The majority of our primary care practices are certified Patient-Centered Medical Homes (PCMH). The Medical Home Care Coordinator is a vital part of the multidisciplinary healthcare team which strives to coordinate care and optimize outcomes for patients and our healthcare system.

Care Transition Coaching and Coordination

• Reduce unnecessary hospitalizations and re-hospitalizations by working with patients who were discharged from various healthcare facilities. Work with the primary care team to ensure follow-up visits are scheduled within 48 hours of facility discharge.

• Use Motivational Interviewing and coaching strategies to help patients identify and meet their healthcare goals.

• Develop individualized care plans to help patients track and meet their goals.

• Provide care coordination strategies via telephonic support and/or face-to-face to engage and educate patients.

• Develop and promote constructive relationships with inpatient, outpatient and community personnel to meet patient needs and goals.

• Guide process and performance improvement initiatives in the primary care setting to meet strategic goals.

• Engage with home care agencies, specialists, and any other integral providers or resources in case management activities.

Population Management

• Prioritize high risk patient needs with physicians, office staff, and the health care team.

• Leverage clinical informatics to identify high risk, high need, and potentially high cost patients of the medical home to manage their care.

• Utilize electronic medical record (EMR) and chronic disease registry reporting to prioritize patient outreach.

• Coordinate with Case Management and Disease Management staff when applicable

Qualifications

Education/Experience:

• RN licensure required. BSN preferred.

• Certified Case Management (CCM) preferred

• Five to eight years of direct patient care experience required

• Must have experience with Microsoft Office (Word, Excel, PowerPoint).

• Must possess the ability to quickly learn new IT systems and software.

• Must be able to adjust and prioritize tasks in a dynamic environment.

• Experience with an EMR strongly preferred

• Experience analyzing, sorting and drawing conclusions from data strongly preferred.