Are you interested in becoming part of an outstanding team of professionals who make patient and family-centered care their priority? We currently have the following opportunity for an energetic, skilled, and compassionate individual like you to become part of the Lake Health team.
The RN Care Coordinator, operationally under the direction of the Care Coordination Department Director, is responsible to the Chief Quality Officer/Vice President, Lake Health, and its clients to facilitate care for populations of identified patients through the coordination of health care services across the continuum.
The RN Care Coordinator works under the clinical direction of the Primary Care Physician, managing a patient/client case load that is inclusive of coordinating identified care needs with physicians, providers, nursing staff and all other health professionals across the care continuum. The overall responsibility of the care manager is to anticipate the patients' and family's needs, coordinate care, delegate to appropriate care team members and ensure positive patient outcomes.
The RN Care Coordinator is responsible for patient/client referral management, patient/client identification, risk stratification, and prioritizing care needs within the scope of professional license, certification, and the Lake Health global mission to deliver comprehensive healthcare. Specific to the RN Care Coordinator is development of individualized care plans, initiation or delegation of interventions, and evaluation of outcomes with the view of oversight to promote patient/client wellness, self-management of identified illness, early symptom recognition, and develop strategies to avoid complications and unnecessary re-admissions. The RN Care Coordinator coordinates patient/client care within an integrated care delivery system that uses a multidisciplinary approach to population health and wellness management.
Essential Job functions:
Conducts a comprehensive client assessment on patients identified as in need. Assessment will be risk stratified into preventative/low/moderate high risk populations. RN Care Coordinator will maintain the required patient/family high risk case load while coordinating oversight of mod to low risk cases.
Creates a Transitional Plan of Care based on identified needs from Low risk/preventative to moderate and High Risk stratified. Transition plan may include preventative health maintenance strategies, to comprehensive risk reduction interventions. Plan of care will be individualized based on clients/patients' needs and capacities. May include use of clinical protocols for referral to specialist
Communicates with Multidisciplinary team: i.e.: Patient/Family, Physician, Acute Care Inpatient case manager; payor case manager; social workers, community support services, lay professionals etc. Communicates with Internal and external resources to include, but not limited to; communication of plan of care goals, coordination of benefits, enrollment in insurance case management/disease management programs, enrollment in pharmaceutical programs, coordination of non-formulary benefits, etc. Advocate for the needs of the patient with third. party payors.
Utilizes multiple teaching -learning strategies and opportunities to assist patients with self-care management. Examples include incorporating evidenced based practice methods of health coaching, patient motivation, and teaching. Educate patients and caregivers in strategies to improve self-care management, education on available resources and services in community to help meet identified needs, effectively use telephonic contacts to educate patient and caregivers and improve their ability to manage illness and care processes.
Participate in Coordination Care Network steering committees activities as it relates to CCN development and Implementation.
Monitors and evaluate patient outcomes data; including HEDIS and NCQA metrics, payor risk metric etc. Assists in the NCQA accreditation process for the PCMH, assures compliance with standards in collaboration with the PCMH quality analyst team; maintain current database of active case load. Evaluates data and develops appropriate plans of care based on patient specific data outcomes.
Participate in Team development Opportunities.
Actively exhibits Both Independent and Departmental Accountability and takes Actions to drive change. (exhibits qualities of a culture of “I saw it, I own it, I'll help to provide a solution).
Supervises and or delegates assignments to Team members within the Coordinated Care network; including but not limited to Social worker, health care coach, dietician, pharmacist etc.
Other duties as assigned.
Education and Experience:
Bachelor Degree preferred but experience will be considered in lieu of BSN. Associates of Nursing required. Active RN, Ohio Licensure; Certified Case Manager certificate, preferred. Five to Ten years Acute Care or PCMH Care Coordination experience.
Lake Health offers free, secure and convenient parking; an aggressive pay structure, tuition reimbursement and continuing education funding programs, a generous and comprehensive benefits package for all eligible positions which includes medical, dental, vision, pension, paid time off; an award winning hospital system recognized for excellence in patient care and as a “Best Place to Work.“
Keywords: RN, Registered Nurse, Nursing, Care Coordinator