Clinic RN - Care Coordination Program Supervisor

Responsibilities

• Works cooperatively within own department and with other employees in other departments.
• Willingly assumes additional responsibility to support the team efforts of own and other departments.
• Consistently uses good written and verbal communication.
• Show the appropriate care, courtesy and respect to all guests, patients, physicians and other employees that they deserve.
• Upholds the highest confidentiality that the hospital requires.
• Maintains a positive attitude under the most trying of circumstances.
• Always have a good and flexible attitude to changes that take place in the department.
• Follows all direction concerning changes and acts accordingly.
• Maintains a well organized and clean environment to work at maximum efficiency and promoting good quality standards.
• Able to use own initiative to figure out problems.
• Care Coordination / Care Management
• Work closely with healthcare providers and interdisciplinary teams to ensure coordinated, comprehensive patient care.
• Manage care for patients with complex conditions, ensuring that each patient's individual care plan is followed and any gaps in care are addressed.
• This includes monitoring care needs, coordinated follow-ups, and ensuring timely interventions as necessary.
• Assists with staff development and problem solving.
• Follow and manage a panel of complex patients, ensuring that their care is properly coordinated across multiple settings, including referrals to specialists, follow-up care, and addressing any emerging patient needs/concerns as they arise.
• Monitor for changes in patient conditions and initiate necessary interventions.
• Apply appropriate charges for care provided when applicable.
• Reach out to patients recently discharged from the emergency room or hospital to schedule follow-up appointments ensuring continuity of care, addresses patient concerns, and supports a smooth transition from acute to outpatient care.
• Inform patient's care provider of any pertinent patient information or care coordination needs post discharge.
• Telephone Triage
• Assess and respond to patient inquiries via telephone, providing appropriate guidance, advice, disposition, and follow-up instructions based on protocol.
• Ensure Timely and accurate advice is provided and coordinate with the healthcare team to facilitate next steps, including referrals or in-person visits.
• Nurse Visits
• Provide direct patient care during scheduled nurse visits (e.g., screenings, immunizations, dressing changes, education, adherence support, diabetes, hypertension, etc.).
• Perform through assessments, administering treatments, and addressing patient needs.
• You will assess each patient's status and use critical thinking to provide ongoing interventions.
• Patient Education
• Educate patients and families on medical conditions, treatment plans, medications, and lifestyle modifications to promote health and wellness.
• Focus on proactive management of chronic conditions, as well as preventive care.
• Provide education on advanced care planning, encouraging patients to make informed decisions about their healthcare.

Qualifications

• Bachelor’s degree in Nursing or related field.
• Current license to practice as a Registered Nurse in the state of [State].
• Experience in a clinical setting preferred.
• Strong communication and interpersonal skills.
• Ability to work independently and as part of a team.
• Knowledge of medical terminology and procedures.
• Basic computer skills, including proficiency in Microsoft Office.