RN Care Coordinator

About the role

The RN Care Coordinator provides a deliberate patient and family centered partnership with the healthcare team that facilitates a seamless patient experience between the Inpatient and Outpatient settings and coordinates patient care through the continuum thereby facilitating the achievement of optimal quality outcomes in relation to clinical care and cost effectiveness.

Responsibilities

The RN Care Coordinator develops and supports a coordinated plan of care between visits to promote a smooth transition for patients and family across the healthcare continuum that instills a sense of trust and patient advocacy. Key responsibilities include:

• Coordinates and manages patient care for high risk and complex patient populations across all elements of the Healthcare System and Patient’s Community
• Identifies patients in need of care management services and collaborates with providers and practice staff to identify patients appropriate for care management
• Works with patients/families to develop an individualized plan for maximizing each patient’s ability to adhere to a health plan formulated with healthcare professionals
• Documents accurately and timely initial and ongoing assessments, including care plan development and evaluation and maintenance of any established database
• Provides patient/family education pertinent to disease progression, health status, wellness need and relevant therapies
• Communicates with external healthcare professionals as appropriate, informing them of the patient’s progress and any potential concerns related to their plan of care and clinical pathway
• Collaborates with and communicates with multidisciplinary care team to provide continuity of care and maintain standards between entities

Requirements

The following requirements are considered essential:

• 1 year of nursing experience, preferably med-surg, critical care or ambulatory
• Experience in care planning, resource management or care management desired
• Prior experience in primary care desired
• Good time management, organizational skills, and critical thinking skills
• Proven experience with an EMR, keyboarding and computer skills
• Demonstrates excellent interpersonal and communication skills and the ability to manage conflict and develop relationships across organization lines using interpersonal communication skills

Qualifications

The following qualifications are considered essential:

• Graduation from an accredited school of nursing
• Current registration as a registered nurse in the State of Maine
• Current BLS certification

Skills

The following skills are considered essential:

• Ability to assess, plan and implement care plan
• Excellent assessment and patient education skills
• Ability to read, interpret, and apply clinic policies and procedures
• Ability to identify problems and recommend solutions
• Ability to establish priorities and coordinate work activities
• Detail-oriented
• Empathy for patients and their families
• Ability to deal with stress