RN Care Coordinator- Registered Nurse- Edgewood Primary Care

Job Type:

Regular

Scheduled Hours:

40

Job Summary:

Reports to Manager of Care Coordination, works collaboratively with providers, (interdisciplinary staff) and clinical associates to support patients with chronic conditions and/or complex needs according to guidelines established by (care transition) the primary care and other clinical programs such as PQRS, PCMH, etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns.

Job Description:

Job Title: Care Coordinator - RN

Non-Exempt

Job Code:  140192

PRIMARY PURPOSE:  

Works collaboratively with providers, (interdisciplinary staff) and clinical associates to support patients with chronic conditions and/or complex needs according to guidelines established by (care transition) the primary care and other clinical programs such as PQRS, PCMH, etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns.

BENEFITS:

• No Nights, Holidays, or Weekends
• Paid Time Off
• Medical, Dental, and Vision
• 403b with Match
• Opportunity for Career Growth

DUTIES & RESPONSIBILITIES:

• Understand and uphold SEP’s Mission, Vision, and Values.
• Comply with all applicable laws and regulations.
• 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. The RN engages in critical thinking to meet patient 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)
• 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
• Must understand professional boundaries and appropriately refer diagnostic questions to MD
• Refer patients appropriately when needs for mental health, pharmacy, social work, respiratory therapy etc. are identified
• Work face to face or telephonically with patients as needed.
• Ensures complete and accurate information in the Electronic Health Record.
• Forward written physician orders for treatment
• Assess patient for additional needs, develop nursing plan of care and contact physician for order-dependent items
• Maintains adequate level of resources for care coordination.
• OSHA and HIPAA compliance.
• Assists with completion of patient requests in a timely manner.
• Timely and accurate complete charting of all patient information
• Other duties and responsibilities as assigned are complete in a timely and accurate manner.
• Maintain good working relationships communications with the 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.

EDUCATION: 

• Current State Allied Health License required, RN.
• Current Driver’s License in good standing and reliable and insured transportation
• Degree in nursing or other related clinical field
• Care Management Certification preferred

YEARS OF EXPERIENCE:

• Three to four years medical field experience
• Demonstrated knowledge of anatomy and physiology, pharmacology, etc.
• Ambulatory and/or care management experience preferred

LICENSES AND CERTIFICATIONS:

• Current state Allied Health license.

REQUIRED SKILLS AND KNOWLEDGE:

• Ability to manage and prioritize multiple tasks.
• Knowledge of electronic Health Records – (EPIC