RN Care Coordinator- Florence (HYBRID Schedule)

Job Summary

Reports to the RN Manager of Care Coordination, the RN Care Coordinator (OCC) works collaboratively with providers, interdisciplinary staff, and clinical associates, in person and telephonically, at any/all SEP offices to support patients with chronic conditions and/or complex needs according to guidelines established by SEP and other clinical programs such as PCF etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns.

About the Role

A RN Care Coordinator- Office Care Coordinator works in person and telephonically as a member of the interdisciplinary team. A RN Care Coordinator- Office Care Coordinator understands and adheres to established best practice care management standards of care. A RN Care Coordinator- Office Care Coordinator understands and coordinates care using evidence based clinical guidelines for chronic disease management.

Dimensions

• Education: Degree in nursing (ADN or higher)
• Licenses And Certifications: Active, unencumbered multistate (compact) RN nursing license issued by a Nurse Licensure Compact (NLC) state, specifically Kentucky, Indiana or Ohio. Care Management Certification preferred.
• Years Of Experience: Minimum of 3 years nursing experience or current care management position held within SEP Clinical Transformation.
• Other Required Skills And Knowledge: Previous Quality Assurance experience preferred

Duties And Responsibilities

• Documents in chart appropriately utilizing care management documentation.
• Provides patient care through collaborating with patients, providing education and clear direction to the patient and address patient concerns regarding care.
• Support Chronic Disease Management and Patient Care Needs: Identify patients with chronic disease, rising risk concerns, social, financial, or educational needs for care management services. Respond to provider referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or blood pressure, Mental Health Integration referral, complex needs).
• Evaluate and collaborate with patients’ and families to determine readiness to change and resources for support. Monitor compliance with plan of care and problem solve barriers to patient self-management. Provide support for patient and family issues, resource needs, and answering general healthcare questions.
• Do ADL assessment and home safety assessments based on patient interview. Identify and place order for services such as HH when patient has identified need. Assess need and provide basic diabetic teaching (glucose meter testing, etc.). Assess need and obtain required order for patient to receive disease management teaching or counseling (MD referral required for billing). Document RN Care Coordinator interventions in Epic within care management documentation. Refer non-nursing functions, such as assisting patients with completion of Medicaid, disability, pharmacy program or other eligibility applications, and scheduling appointments to designated resources in the region. Coordinate with care managers in other settings as appropriate.
• Carry out assessments and make decisions on his or her own before seeking the support of a supervisor. Assist providers, patients, and families with Advance Care Planning. Explain results from screening based on protocol and guidelines. The RN is expected to perform medication reconciliation for each patient on their panel. Provides ongoing management for chronic conditions, working with patients to meet healthcare goals per cadence expectations. Patient Education: Provide education and pre-printed, SEP approved educational materials as needed, or at provider or patient request Work collaboratively with patients to assess needs and develop a patient education plan of care. Answer clinical questions related to patients’ chronic health conditions. Provide group education for established patients.
• Maintain good working relationships communications with all interdisciplinary team members, management, and utilization review staff for coordination of care and care transitions. Work with providers, interdisciplinary staff, and office staff to identify appropriate patient population for advance care planning. Work directly with patient to educate, provide resources, and manage their disease processes. Manage and perform home visits with patients as needed if a component of care management expectations. Attend meetings as required. In office support for nursing tasks such as: PPD, IRIS Exams, CGM starts, etc. Collaborative communication with office staff to be available for warm hand offs and immediate patient needs. Assessment of medication affordability and assisting patients with identified needs.

Required Skills And Knowledge

• Ability to manage and prioritize multiple tasks.
• Knowledge of electronic Health Records – (EPIC)
• Knowledge of Excel, Word, Outlook and PowerPoint and the ability to learn other computer skills as needed.
• Good organizational skills.
• Work professionally with doctors, hospital administration and management, SEP associates and the public.
• Organized, neat and self-motivated.
• Warm personality with concern for others.
• Excellent verbal and written communication skills.
• Excellent interpersonal skills.
• Ability to affect change.
• Ability to perform critical analysis.
• Self-directed
• Work well telephonically as well as face to face.
• Can work autonomously.
• Be familiar with motivational interviewing with patients.
• Positive attitude
• Quest for learning and excellence.