The Care Coordinator RN is a member of an interdisciplinary team that influences and achieves optimal clinical and resource outcomes. This is achieved by identifying and stratifying the patient population in accordance with the Catholic Health population care management program and providing proactive care management services to high risk patients with chronic health conditions in order to: reduce the burden of illness, improve compliance with evidence based clinical guidelines, encourage patient self-management, increase coordination of care, increase the utilization of resources and services across the continuum and improve patient experience of care while reducing the total cost of care. The Care Coordinator serves as a change agent for clinical performance and process improvement and provides operational and clinical support to the site Office Manager. The Care Coordinator oversees the efforts of the Quality LPN at the site level and identifies opportunities for improvement and focus.
Responsibilities:
EDUCATION REQUIRED
Graduate of an accredited school of professional nursing
Bachelors of Science Degree in Nursing required
Current, unrestricted licensure by New York State as a Registered Nurse (RN) required
WORK EXPERIENCE
Minimum of (1) year experience as a registered nurse required
One year previous case, disease, or utilization management experience preferred
One year previous experience in a physician office or ambulatory care setting preferred
KNOWLEDGE, SKILL, AND ABILITY
Ability to use an electronic medical record (EMR), patient registry and running reports from an EMR
Effective verbal and communication skills
Solid command of the English language
Ability to teach, motivate and influence others
Demonstrated ability to work effectively in a interdisciplinary team to facilitate the efforts of the primary care team to assist patients in meeting their goals
Demonstrated effective interpersonal relationship and customer service skills
Excellent organizational and time management skills
Demonstrates understanding of evidence based guideline (EBG) and knowledge of EBGs adopted by the practice
Understands and applies performance improvement methods to support the practice in attaining CMP CI Plan goals
Ability to convey complex clinical information in a simple, concise way
Ability to evaluate patient readiness to change
Ability to facilitate patient development of SMART goals in a patient centric care plan
Ability to work effectively with people from diverse cultures and socioeconomic conditions
Actively listens to others to understand their perspective and ensure understanding regardless of barriers
Critical thinking capability
Ability to handle protected health information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Knowledge of community resources
WORKING CONDITIONS:
Occasional local travel between sites may be required
May be exposed to infections and contagious diseases
Occasional exposure to unpleasant patient elements
Contact with patients under wide variety of circumstances
Exposed to unpleasant elements (accidents, injuries and illness)
Subject to varying and unpredictable situations in a physician office setting
Handles emergency or crisis situations
Subject to many interruptions
Occasionally subjected to irregular hours, handles absentee replacement on short notice, flexibility in scheduled working hours/days to meet needs of clinic
Ability to multitask in a fast paced office environment, occasional extreme heavy physical effort (lift/carry 50 lbs. or more)
INTERNAL/EXTERNAL RELATIONSHIPS:
INTERNAL: Works cooperatively with physicians, APP's, nursing, ancillary support and office staff
EXTERNAL: Patients and their families, various medical practices, facilities and service providers, professional organizations, community service organizations, accrediting and regulatory agencies (JCAHO, CMS) and insurance companies REQNUMBER: 29220
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