Population Health RN Care Coordinator

Major Duties And Responsibilities

• Analytical and Critical Thinking
• Develop systems and processes to engage patients in self-management and care navigation.
• Ensure 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.
• 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.

WORKING CONDITIONS/PHYSICAL DEMANDS

• Work is typically performed in an office environment.
• Depending on client/population needs, may also include clinical and community and/or home-based activities, as appropriate to program.
• The specific statements shown in each section of this description are not intended to be all-inclusive.