Nurse Care Coordinator

Description

Organization: Quality Healthcare Development

Location: Charleston, SC

Employment Type: Full-Time

FLSA Status: Exempt (Professional Exemption)

Reports To: Quality Director

Position Summary

Quality Healthcare Development is seeking a Nurse Care Coordinator responsible for developing and implementing a comprehensive care coordination program in partnership with the Quality Director. This role focuses on engaging and supporting patients within the Accountable Care Organization (ACO) population to improve care quality, enhance patient outcomes, and reduce the overall cost of care.

The Nurse Care Coordinator works closely with patients, families, providers, and the healthcare team to coordinate services and resources across the continuum of care. This role promotes patient engagement, self-management, and shared decision-making while improving health literacy for patients and caregivers. The position also serves as a liaison between patients, providers, and community resources to ensure coordinated, efficient, and patient-centered care.

Requirements

Key Responsibilities

Care Coordination Program Development

•  Participate in program development, evaluation, and improvement initiatives.

Patient Care Coordination

•  Perform key functions related to the success of the Care Coordination Program including patient outreach via telephone and occasional office encounters.
•  Maintain regular communication with patients in the assigned caseload.
•  Coordinate patient activities and ensure appropriate utilization of healthcare services.
•  Support care gap closure and ensure appropriate follow-up care.

Patient and Family Engagement

•  Include patients’ family members, caregivers, and support systems in care coordination activities when appropriate.
•  Promote patient engagement, self-management, and shared decision-making.
•  Ensure patients and caregivers understand condition management, medications, tests, referrals, and recommended services.

Care Planning and Collaboration

•  Work collaboratively with patients, providers, and healthcare teams to develop care plans that maximize health outcomes and cost-effective care.
•  Consult with providers and healthcare team members to address care issues and barriers to treatment.

Care Transitions and Resource Coordination

•  Coordinate care across the continuum including post-discharge follow-up calls for hospitalized patients.
•  Assist patients in accessing community resources and financial assistance when appropriate.
•  Identify and address barriers to treatment plan adherence.

Patient Education and Health Literacy

•  Utilize motivational interviewing and other strategies to promote patient engagement and improved health outcomes.
•  Assess and implement strategies to improve patient and caregiver health literacy.
•  Provide education and resources necessary to support informed healthcare decisions.

Monitoring and Documentation

•  Monitor the effectiveness of care plans and revise as necessary in collaboration with patients and the healthcare team.
•  Document all patient care coordination activities accurately and in a timely manner.
•  Serve as a patient advocate throughout the care coordination process.

Compliance and Quality Improvement

•  Participate in quality improvement initiatives and care coordination program evaluations.
•  Maintain strict adherence to HIPAA regulations and patient confidentiality requirements.
•  Demonstrate awareness of and responsiveness to cultural and demographic diversity within the patient population.

Required Knowledge & Skills

•  Strong interpersonal communication and organizational skills.
•  Ability to work independently, take initiative, and identify opportunities for professional growth.
•  Strong critical thinking and problem-solving abilities.
•  Ability to quickly assess and prioritize patient needs.
•  Experience engaging patients through telephone outreach and care management activities.
•  Comprehensive knowledge of chronic health conditions and clinical assessment parameters.
•  Strong knowledge of healthcare systems and care navigation.
•  Flexibility and adaptability in a dynamic healthcare environment.
•  Proficiency in basic computer applications and electronic medical record systems.

Education, Experience & Licensure

Education

•  Bachelor’s degree in Nurs