RN Care Coordinator Pre-Post Natal - Care Transformation - FT - Day

Position Status:

Full time

Shift:

First Shift (Days - Less than 12 hours per shift) (United States of America)

Hours per week:

40

Job Information
Exemption Status: Non-Exempt

A Brief Overview
The Care Coordinator serves in an expanded nursing role to collaborate with patients and their health care team including Primary Care Providers, specialists, and hospitals to provide a model of care that ensures the delivery of quality, efficient and cost-effective healthcare services across the continuum. The Care Coordinator functions as a coordinator of patient care, assesses, plans, implements, monitors, and evaluates all options and services with the goal of optimizing the patient's health status. The Care Coordinator integrates evidence-based clinical guidelines, preventative guidelines, protocols, and other metrics in the development of transitions of care plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the targeted high-risk population. The Care Coordinator monitors patients across the health continuum with a focus on effective and safe transitions through the healthcare system with a goal to optimize resources and reduce avoidable readmissions back to acute care. The Care Coordinator manages performance feedback metrics to further refine the care model to maximize clinical, quality, and fiscal outcomes for the targeted population. The delivery of professional nursing care at Stormont-Vail HealthCare is guided by Jean Watson's Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization.

Education Qualifications

• Bachelor's Degree of Science in Nursing (BSN) Required

Experience Qualifications

• 2 years Nursing experience in an acute or ambulatory setting. Required

• Case/care management experience. Preferred

Skills and Abilities

• Demonstrates prudent professional and clinical judgement, effective problem solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task.

• Demonstrates ability to be self-directed and purposeful in seeking the necessary knowledge and skills to enhance professionalism in order to provide high-quality care.

• Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.

• Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.

• Demonstrates ability to work autonomously and be directly accountable for practice.

• Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, priority setting, and work organization.

Licenses and Certifications

• Registered Nurse - KSBN Required

• Drivers License - DMV Current Valid Driver’s License and Clean MVR with 3-year baseline and annual MVR review. Required

• Basic Life Support - BLS Required within 90 days of hire.

What you will do

• Collaborates with specialty, primary care, social work staff, and other care team members to ensure optimal care coordination for the patient.

• Serves as the point of contact for their patient population, or the care team to coordinate/manage health needs.

• Initiates communication with patients upon learning they have been identified as high risk / targeted population.

• Pulls data from multiple systems and merge together to create a complete performance picture related to targeted populations. Implements interventions based on data and established guidelines. Monitors data for trends and individual outliers. Analyzes data for process improvement opportunities to impact patient outcomes.

• Optimizes patient care transitions by: o Collaborates with inpatient teams to support discharge plans o Coordinates post-hospitalization care and discharge planning o Assures collaboration with primary care, social work & PCP care manager, other care team members, and community supports to ensure optimal care coordination for the patient

• Guides patients through the health care system o Facilitates interaction and