Registered Nurse Care Coordinator - Full time

Responsibilities

• Performs initial, holistic assessments for care coordination population.
• Prioritizes patients according to intensity, need, and required follow-up.
• Delegates periodic care coordination as appropriate when working with an LPN Care Coordinator.
• Provides education regarding disease management based on current best practice standards.
• Triages patients escalated for re-evaluation by the LPN Care Coordinator.
• Knowledge of current federal, state, and local programs as well as their eligibility requirements and application process to proactively connect patients with appropriate resources.
• Develops care coordination plans and goals mutually agreed upon by patient/family.
• Utilizes motivational interviewing techniques and assists patient in meeting action-oriented goals and objectives.
• Evaluates effectiveness of plans in meeting established care goals, revises as needed when working with an LPN Care Coordinator.
• Collaborates for patients who may need care plan and goal revision when working with an LPN Care Coordinator.
• 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.
• Delegates weekly follow up calls until the patient has been discharged for 30 days.
• 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 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 to close care gaps.
• Reports findings to provider.
• 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.
• Triage patients escalated by LPN Care Coordinator for review/updating of care plan.
• Revise 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 identifies patients needing additional support of care management.
• Participates in regular team meetings.
• Participates in departmental and organizational committees as applicable.
• Serves as liaison to providers, patients and families for coordination of services.
• Precepts and acts as a mentor to peers.
• Promotes collaborative teamwork.
• Maintains accurate and timely documentation and billing.
• Attends conferences, workshops, and completes continuing education as assigned.

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.