RN Care Coordinator (Float)

Job Type:

Regular

Scheduled Hours:

40

Job Summary:

Reports to the RN Manager of Care Coordination, the RN Care Coordinator (Float) works collaboratively with providers, interdisciplinary staff, and clinical associates, in person and telephonically, at any/all SEP offices to support patients with chronic conditions and/or complex needs according to guidelines established by SEP and other clinical programs such as PCF etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns. A RN Care Coordinator Float role requires travel to any/all SEP offices per manager discretion.

DIMENSIONS:
A RN Care Coordinator- Float works primarily in the ambulatory setting and is a member of the physician led interdisciplinary team. A RN Care Coordinator- Float understands and adheres to established best practice care management standards of care. A RN Care Coordinator- Float understands and coordinates care using evidence based clinical guidelines for chronic disease management.

Job Description:

Job Title: SEP - RN Care Coordinator (Float)

PRIMARY PURPOSE:

Reports to the RN Manager of Care Coordination, the RN Care Coordinator (Float) works collaboratively with providers, interdisciplinary staff, and clinical associates, in person and telephonically, at any/all SEP offices to support patients with chronic conditions and/or complex needs according to guidelines established by SEP and other clinical programs such as PCF etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns. A RN Care Coordinator Float role requires travel to any/all SEP offices per manager discretion.

DIMENSIONS:
A RN Care Coordinator- Float works primarily in the ambulatory setting and is a member of the physician led interdisciplinary team. A RN Care Coordinator- Float understands and adheres to established best practice care management standards of care. A RN Care Coordinator- Float understands and coordinates care using evidence based clinical guidelines for chronic disease management.

DUTIES AND RESPONSIBILITES:

• 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. 
• Support Chronic Disease Management and Patient Care 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)
  - Evaluate and collaborate with patients’ and families to determine readiness to change and resources for support.
  - Monitor compliance with plan of care and problem solve barriers to patient self-management.
  - Provide support for patient and family issues, resource needs, and answering general healthcare questions.
  - Do ADL assessment and home safety assessments based on patient interview.
  - Identify and place order for services such as HH when patient has identified need
  - Utilize teach back method for pts who have no medical necessity to justify home health.
  -  Assess need and provide basic diabetic teaching (glucose meter testing, etc.)
  -  Assess need and obtain required order for patient to receive disease management teaching or counseling (MD referral required for billing)
  -  Document RN Care Coordinator interventions in Epic within care management documentation. 
  - Refer non-nursing functions, such as assisting patients with completion of Medicaid, disability, pharmacy program or other eligibility applications, and scheduling appointments to designated resources in the region.
  - Coordinate with care managers in other settings as appropriate.
  - Carry out assessments and make decisions on his or her own before seeking the support of a supervisor.
  - Assist providers, patients, and families with Advance Care Planning
  - Explain results from screening based on protocol and guidelines.
  -The RN is expected to perform medication reconciliation for each patient on their panel.
•  Patient Education:
  - 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 pa