A RN Care Coordinator works closely with primary care physicians and various specialty physicians and services to maximize the health status of patients. This position requires a high frequency of contact with the high risk ACO patient and their care givers for education of health promotion and self care skills as well as facilitating compliance with the required quality measures for all ACO patients.
Identify patient and care giver learning needs, assess their ability to learn, in order to formulate a comprehensive teaching program individual to that patients unique health issues. Review medical records to identify gaps in care and coordinate services.
Perform needs assessments of high risk patients (with their input) to maximize or improve current health status and independence while preventing or slowing deterioration of existing health problems. Perform extensive telephonic or face-to-face assessment and triage of patients. Monitor and facilitate compliance with required quality measures for ACO patients.
Works collaboratively with physicians in all settings to ensure patient adherence to medical plan, including all appropriate preventative and disease-specific screenings, interventions, and treatment goals including self-management goals.
Communicate with physician offices to optimize patient care, decrease costs and increase patient satisfaction. Work within the multi-disciplinary team to create new and update existing tools.
Utilize clinical tools such as protocols, physician orders, and care coordination models to maximize patient care. Communicate with the primary physician, patient or care giver, and any transitional care staff that are available, such as Hospitalists, Care Managers, Social Workers, etc. Directly involved with the development and enhancement processes of the ACO with the aim to improve the clinical experience and satisfaction of services for patients and/or physicians.
Basic professional knowledge; equivalent to a Bachelor's degree; working knowledge of theory and practice within a specialized field.
BSN preferred. ADN required. 3 to 5 years of experience
Facility: Part of LifeBridge Health, Sinai Hospital of Baltimore features state-of-the-art facilities and renowned Centers of Excellence some with national and international acclaim.
As the largest community hospital and the third largest teaching hospital in Maryland, Sinai Hospital's mission is to provide quality patient care, educate medical students and residents, and engage in research to improve the lives of people all over the world. Sinai Hospital is a smoke-free workplace. M/F/PV/IWD Employer Requisition Number: 48619 Department:
HSCRC LBH TRANSFORMATION GRANT Schedule: Full-time Shift: Day shift Hours: 8:00am- 4:30pm
Lifebridge Health, Inc.