RN Care Coordinator Ambulatory Transitions of Care

Provides care management and care coordination for patients following an acute care hospitalization. Uses evidence-based interventions and defined workflows to support successful transitions of care.

Responsibilities

• Collaborate with members of the health care team to ensure the delivery of quality, efficient, patient-centered, and cost-effective healthcare services.
• Identify targeted high-risk and chronically ill populations within practice sites using a variety of methods and tools.
• Assess the healthcare, educational, and psychosocial needs of the patient/family using appropriate assessment tools such as depression screening, functionality, and health risk assessment.
• Collaborate with Primary Care Physician, patient, and members of the health care team to assess, develop, and implement an agreed-upon plan of care.
• Participate in continuous quality improvement to enhance care management in the office setting.
• Monitor patient/family response to plan of care and revise the care plan as indicated.
• Provide self-management support with a focus on empowering the patient/family to build capacity for self-care.
• Ensure support for advanced directives and advanced care planning.
• Conduct comprehensive assessments to identify the member’s needs, self-management goals, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk or barriers that may impact adherence to the care management plan.
• Identify patients with chronic conditions and gaps in clinical care using evidence-based guidelines and clinical tools.
• Implement systems to ensure necessary care is completed and monitor individual patient progress and population health.
• Coordinate patient care by linking patients to resources and provide follow-up during transitions between care settings.
• Complete post-hospital discharge calls including medication reconciliation, coordinate physician follow-up appointments, symptoms assessment, patient education/discharge instructions, and problem-solve barriers to compliance.
• Maintain required documentation for all care management activities.
• Work with practice and Physician Organization/Accountable Care Organization leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies.
• Review current literature regarding effective engagement, communication, care management, and behavior change strategies, and incorporate into clinical practice.
• Provide education on management of chronic conditions and enhance the member’s self-efficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change.
• Coordinate care transitions and monitor high-risk members following hospital and sub-acute discharges to ensure timely follow-up with primary care and prevent readmissions.

Requirements

• Associate's Degree or equivalent Graduate of an accredited school of nursing (Required).
• Bachelor's Degree of Science in Nursing (Preferred).
• Minimum two years’ RN experience in a clinical care setting (Required).
• Three to five years’ experience in care management, home care, and/or discharge planning (Required).
• Experience in an ambulatory practice setting (Preferred).
• Registered Nurse (RN) - State of Michigan license (Required upon hire).
• At least one License and/or Certification in area of specialty - Care Management (Preferred upon hire).

Benefits

• Comprehensive benefits package to meet financial, health, and work/life balance goals.
• On-demand pay program powered by Payactiv.
• Discounts directory with deals on restaurants, phone plans, spas, and more.
• Optional identity theft protection, home, and auto insurance.
• Traditional and Roth retirement options with service contribution and match savings.

Schedule

• Full time, Day shift.
• 40 hours per week, 8:00 a.m. to 4:30 p.m.
• Monday to Friday.
• Required three to six month orientation period at the Corewell Health Southfield Center, followed by a transition to a work-from-home arrangement with occasional time in the office as required.