Registered Nurse - Care Coordinator - Full Time

About the role

As one of the nation's Top 15 Health Systems, recognized by Premier and Modern Healthcare, Valley Health is a place where excellence, compassion, and purpose come together. This distinction reflects our commitment to exceptional patient care, clinical quality, and the caregivers who make it all possible.

The Registered Nurse Care Coordinator collaborates with providers and clinic staff to identify and prioritize patients appropriate for care coordination services, utilizing care coordination criteria.

Responsibilities

• Performs initial, holistic assessments for care coordination population.
• Prioritizes patients according to intensity, need, and required follow-up.
• Provides education regarding disease management based on current best practice standards.
• Triages patients escalated for re-evaluation by the LPN Care Coordinator.
• Develops care coordination plans and goals mutually agreed upon by patient/family.
• Utilizes motivational interviewing techniques and assist patient in meeting action-oriented goals and objectives.
• Evaluates effectiveness of plans in meeting established care goals, revise as needed.
• Interacts professionally with patient/family to achieve maximum levels of wellness and independence.
• Performs initial calls for patients recently discharged from the hospital who are considered high risk for readmission.
• Ensures that the patient has attended follow up appointments as scheduled and is adherent to medications.
• Provides patient with education regarding hospital diagnosis.
• Identifies patients who have had a change in condition and escalates care to provider or EMS services as appropriate.
• Performs face-to-face patient visits in order to update medical/surgical/family history, review current medications and allergies, assess social determinants of health, provide appropriate health screenings, assess for functionality, and review medical record for gaps in care.
• Conducts shared decision-making conversations with patient in order to close care gaps.
• Reports findings to provider.
• Assists patients in developing advanced care planning.
• Serves as liaison to providers, patients and families for coordination of services.
• Maintains EMR databases on care managed population.
• Maintains accurate and timely documentation and billing.
• Triages patients escalated by LPN Care Coordinator for review/updating of care plan.
• Revises care plan at least once per year according to standards set by CMS.
• Reviews utilization and quality reports routinely, scans for gaps in care and identify patients needing the additional support of care management.
• Participates in regular team meetings.
• Participates in departmental and organizational committees as applicable.
• Participates in the orientation of new personnel.
• Precepts and acts as a mentor to peers.
• Promotes collaborative teamwork.
• Meets with Manager of Population Health Outpatient Care Coordinator and if applicable the LPN Care Coordinator team member on a regular basis to provide patient updates, identify issues, and develop strategies for resolution.

Qualifications

Nursing (BSN) is required.

3 years relevant nursing experience including a minimum of 2 years’ nursing case management experience, preferably with older patients, preferred.

Navigation Experience In Outpatient Setting Preferred.

Registered Nurse license required.

Based on primary state of residency and in accordance with current West Virginia or Virginia Board of Nursing Regulations, must be licensed or eligible to practice pending licensure as a Registered Nurse in the West Virginia or the Commonwealth of Virginia with either a multi-state license, under the Nurse Licensure Compact OR Single-state license, valid in West Virginia or Virginia only.

BLS Certification (Basic Life Support) - American Heart ‘Healthcare Provider’ (HCP) - AHA approved required.

New hires must have American Heart Association (AHA) appropriate certification prior to completion of orientation.

Case management certification is preferred.

Experience in one of the following required: previous Navigation Experience in outpatient setting, Case Management, or Home Health/Public Health.

Knowledgeable in stages of human growth and development for adult and geriatric populations.

Skills in interpersonal relationships, clinical assessment, group process and high levels of verbal and written communication.

Ability to interact with other professionals as part of a multidisciplinary team, displaying good judgment and decision-making skills.

Self-directed with the proven ability to work independently essential.

Knowledge of funding, resources, clinical standards and outcomes for population.

Benefits

At Valley Health, we believe everyone is a caregiver, and our goal is to create an environment where our caregivers thrive physically, financially, and emotionally.

• A Zero-Deductible Health Plan
• Dental and vision insurance
• Generous Paid Time Off
• Tuition Assistance
• Retirement Savings Match
• A Robust Employee Assistance Program to help with many aspects of emotional wellbeing
• Membership to Healthy U: An Incentive-Based Wellness Program

Valley Health also offers a health savings account & flexible spending account for childcare, life insurance, short-term and long-term disability, and professional development.

In addition, several perks come with working for the largest employer in the region, such as discounts to on-campus dining, and more.