Registered Nurse (RN) - Care Coordinator, Case Management

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Department

Job Summary

Under general supervision, the RN Hospital Care Coordinator is responsible for facilitating and coordinating the care delivered to an assigned group of patients through multidisciplinary and patient/family collaboration to ensure quality and cost-effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment, planning, support, and evaluation of patient care and related outcomes. Activities to be performed are screening for high risk and transition of care needs, interviews with patient/family, and progression of care facilitation with the healthcare team. The Care Coordinator is an active contributor in the development of systems (e.g., care maps, clinical paths) to improve the care of assigned patient populations and to move along the continuum.


Essential Functions:

• Review Status and Level of Care Management
  • Ensures barriers are identified and escalated as needed.
  (35%)
• Clinical Care Screening and Resource Management
  • Upon referral conducts an initial clinical and psychosocial screen through review of the patient’s medical record, interview with the patient/family members and discussion with the physician and other healthcare team members.
  • Monitors the patient’s treatment plan, medical goals and prescribes services to facilitate provision of services/referrals that are needed to meet the needs of the patient during hospitalization thus driving the clinical care process.
  Coordinates any needed referrals, PT/OT, wound care, dietary, pharmacy, cardiac rehab, etc. to facilitate efficient patient flow through the hospital system.
  • Participates in Care Conferences and Care Rounds as required and assists with the development of care plans that will meet the patient’s current and continuing healthcare needs.
  • Ensures that services are appropriate for the patient’s level of care and identifies any test/procedure that could be done as an outpatient and discusses alternative with the physician.
  (35%)
• Risk Assessment and Transition of Care Screening
  • Identifies all readmissions within 30 days and initiates a readmission risk assessment within 24 hrs of identification.
  • Communicates the results of the risk and transition of care screening processes to the physician(s) and other healthcare team members, including external Case Managers and community-based clinic providers, as identified.
  • Generates a referral to the assigned Clinical Social Worker partner for implementation and collaboration of the transition of care plan throughout the hospital stay, as needed.
  • Supports the development and implementation of the patient’s transition of care plan working collaboratively with the Clinical Social Work partner.
  • Communicates any clinical changes that would alter the transition of care plan to all healthcare team members, especially the Clinical Social Worker.
  • Ensures state and federal regulations/rules and insurance company requirements/processes are met.
  • Documents the initial transition of care screening information in the patient’s clinical record according to departmental policies and procedures.
  (30%)

Education:

• Associate's Degree Completion of a nursing education program that satisfied the licensing requirements of the Colorado Sate Board of Nursing for Registered Nurses Required and

Work Experience:

• 3 years of clinical inpatient experience Required

Licenses:

• BLS-Basic Life Support (BLS/CPR) - AHA - American Heart Association Required
• RN-Registered Nurse - DORA - Department of Regulatory Agencies Required
• CCM-Certified Case Manager - ANSI - American National Standards Institute Preferred

Knowledge, Skills and Abilities:

• Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment required.
• Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
• Evidence of leadership, creativity, integrity and initiative required.
• Ability to work effectively in a team environment.
• Experience with windows-based computer programs and ability to use computer for data analysis and data display required; must be able to type 35 words/minute.
• EPIC experience a plus.

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation.

As Colorado’s primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.