Population Health RN Care Coordinator

JOB SUMMARY:

The Nurse Care Coordinator delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing and care management, the Nurse Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals. The Nurse Care Coordinator will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The Nurse Care Coordinator also serves as a role model and mentor to CBHC staff on best practices in care coordination, motivational interviewing and addressing social determinants of health. Assures compliance with regulatory body standards (including Joint Commission, HRSA, PCMH, and grant funding sources).

MAJOR DUTIES AND RESPONSIBILITIES:

Analytical and Critical Thinking

* Work to develop systems and processes to engage patients in self-management and care navigation.

* Ensure that appropriate community resources, home care and ancillary services are in place and being delivered.

* Identify high and rising-risk, high-need, and potentially high-cost patients within the assigned panel of Chase Brexton Health Care patients

* Identify patients at risk for poor outcomes and those who may require more intensive services; provide additional outreach and frequent follow up (by phone and in-person) to this population.

* Provide complex case management, including chronic disease case management, care coordination, transition care management, high risk clinical tracking, and complex medication management to appropriate patients.

* Access appropriate resources inside and outside the organization to meet the needs of the patient.

* Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication.

Teamwork

* Role model and mentor others, including RN Care Managers, to assess and address the physical, functional, social, psychological, environmental, learning and financial needs of patients.

Communication

* Deliver, and assist others to also provide, appropriate interventions which demonstrate knowledge of, and sensitivity toward, cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy.

* Facilitate disease prevention and health promotion with nursing staff, patients and families.

Patient Focus

* Provide education, information, and support related to care goals of patients.

* Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan.

Checking, Examining, and Recording

* Maintain accurate patient records and patient confidentiality.

Willingness to Learn

* Engage in professional development activities to keep abreast of care management practices and patient engagement strategies.

* Attend training sessions and staff meetings as assigned.

SKILLS AND ABILITIES:

* Able to prioritize competing responsibilities and manage complex caseloads.

* Motivational interviewing skills.

* Supportive coaching and mentorship to colleagues at clinic sites, including RN Care Managers, around care coordination and addressing social determinants of health.

* Experience with documentation in an Electronic Medical Record

* Ability to work with computers in word processing, and database applications preferred.

* CPR certified by scheduled start date.

* Must be flexible and adapt to a changing environment.

EDUCATION AND/OR EXPERIENCE:

* Graduate from an Accredited School of Nursing; Current Maryland Nursing License

* At least five years of related nursing experience serving vulnerable clients in a community-based, home-based, or ambulatory care setting.

* Chronic disease management experience

* Encouraged to maintain membership in professional organizations such as the AAACN, ANAC, etc.

* Preferred: Case Management Certification