Care Coordinator - Temporary

About the role

The Registered Nurse Care Coordinator is responsible for the overall care coordination of medically complex patients, including medical care, education, internal and external referrals, and referrals to community resources. The Care Coordinator works with each patient to develop a patient-centered plan of care specific to their needs and self-management goals. Additionally, the Care Coordinator actively collaborates with the diverse healthcare team and local community partners to improve patient health outcomes.

Responsibilities

• Performs the nursing process through assessment, planning, implementation and evaluation of safe therapeutic care to develop patient-entered plan of care to medically complex patients.
• Actively collaborates with healthcare team as an advocate.
• Assists patients through the healthcare system and community by acting as a patient care coordinator.
• Facilitates health and disease patient education through individual teaching and class teaching as indicated.
• Supports patient self-management of disease and behavior modification interventions.
• Assures home monitoring and patient knowledge that is consistent with treatment plan as indicated.
• Collaborates with internal and external healthcare providers to coordinate continuity of patient care.
• Attends clinic visits, field visits and home visits as indicated to monitor patient progress and assess needs.
• Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Facilitates patient medication management based upon medication reconciliation process.
• Connects to community resources as indicated per Social Drivers of Health assessment.
• Participates on a team for data collection, health outcomes reporting, and clinical audits.
• Demonstrates System Values in performance and behavior.
• Complies with System policies and procedures.

Qualifications

• Minimum Education/Experience: Associate's Degree from a National League of Nursing (NLN), Commission on Collegiate Nursing Education (CCNE) or equivalent accredited school of nursing.
• Required Licenses/Certifications: California Registered Nurse (RN), Nevada Registered Nurse (RN), Basic Life Support (BLS) for Healthcare Providers.
• Other Experience/Qualifications: Self-disciplined, energetic, passionate, and innovative; collaborative team member that follows systems and protocols to achieve a common goal; highly organized and well-developed oral and written communication skills; demonstrates sound judgment, decision-making and problem-solving skills; ability to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations; confidence to communicate and outreach to other community health care organizations and is aware of community resources; demonstrated computer skills; proficiency using Electronic Medical Record (EMR); 6 months to 1 year relevant experience.