Care Coordinator RN - Brasher Falls

HOW WE CARE FOR YOU

At St. Lawrence Health, we are dedicated to getting health care right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for your career while caring for the community.

• Same Day pay through Daily Pay

• Paid vacation & holiday pay

• Medical, dental, vision, hearing benefits

SUMMARY:
The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach. Facilitates “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered that address. Acts as a liaison between patients and the healthcare system. Ensures that patients receive the care they need and that they understand their medical condition, medications, and other instructions. Coordination of patient-care services to help reduce costs by reducing duplication of services.

St. Lawrence Health (SLH) was established in December 2013 with the mission to improve health and to expand access through coordination and integration of services. SLH became an affiliate of Rochester Regional Health (RRH) in January 2021. Working together with our community partners, including local health departments and agencies, we are focused on disease prevention, promoting access to quality healthcare services, and improving the overall quality of life for our communities.

STATUS: Full-Time

LOCATION: Brasher Falls, Norfolk, Louisville

DEPARTMENT: Primary Care

SCHEDULE: 8-hr shift variable

ATTRIBUTES

• Required: Completion of an accredited Registered Nurse training program. BSN preferred.

• Required: Current, unrestricted New York State registered professional nursing license

• Required: Certification through the American Academy of Ambulatory Care Nursing in Care Coordination and Care Transitions required within 18 months of employment required.

• Required: Chronic Disease Self-Management Certification required within 12 months of employment.

• Required: Willingness to obtain ongoing and up to date population specific education ​

• 3-5 years’ experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.

• Experience with Patient-Centered-Medical Home desirable.

• Experience with health IT systems and reports is desirable

• Local knowledge about and connections to community health care and social welfare resources is desirable

• Ability to speak a relevant second language is desirable

RESPONSIBILITIES ​

Care Coordination

• Systematically identifies individual patients and plans, manages and coordinates their care, based on condition, needs and on evidence-based guidelines based on quality goals of organizations and population needs.

• Provides assessment, care planning and coordination, and advocacy to patients and their families.

• After assessing the health status of patients, develops, formulates, implements, and revises self-management care plans with a shared-goal model, incorporating patient specific education as appropriate for high risk patients and others, as defined by the practice.

• Evaluation of patient responses to interventions, identifying and developing strategies to barriers in achieving positive clinical outcomes.

• Coordinates care with community and regional ancillary health services for extended needs of patients and ensures that patient specific care plans are developed and documented by the practice clinical team.

• · Educates patient/family regarding relevant wellness issues, disease process, and treatment plan, if not bringing to the attention of the physician.

• Educates patients with appropriate method suitable for individual learning abilities regarding diet, medication, or test needs, if not bringing to the attention of the physician.

• Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.

• Promote timely access to appropriate care.