Overview Care Coordinator Registered Nurse - Behavioral Health - Per Diem. The Care Coordinator works in collaboration with chronically ill or “high-risk” patients and their family/caregivers, clinic/hospital/specialty providers, and community resources in a team approach. Facilitates a shared goal model within and across settings to achieve coordinated high-quality, patient- and family-centered care. Acts as a liaison between patients and the healthcare system to ensure patients receive the care they need and understand their medical condition, medications, and instructions. Coordinates patient-care services to help reduce costs by reducing duplication of services.
Responsibilities Care Coordination: Systematically identifies individual patients and plans, manages and coordinates their care based on condition, needs, and evidence-based guidelines aligned with quality goals of the organization.
Develops, formulates, implements, and revises self-management care plans with a shared-goal model, including patient-specific education for high-risk patients.
Evaluates patient responses to interventions and develops strategies to address barriers to positive clinical outcomes.
Coordinates care with community and regional ancillary health services and ensures patient-specific care plans are developed and documented by the practice clinical team.
Educates patients using appropriate methods for individual learning abilities regarding diet, medication, or test needs, and communicates with the physician as needed.
Assists with data collection and generation of patient registry reports.
Attends and participates in team/educational conferences as needed.
Care Delivery Maintains safe and effective nursing care, adjusting care processes to ensure optimal patient care.
Triage patient phone calls.
Leads patient care team in daily and/or weekly huddle discussions.
Coordinates care with community resources for high-risk patients as defined by the practice.
Coordinates and leads patient support groups and/or shared medical appointments.
Participates in Performance Improvement/Continuous Quality Improvement activities as assigned.
Other duties may be assigned or changed to meet business needs.
Required Qualifications AAS in Nursing
Valid NYS RN License
Preferred Qualifications BS in Nursing
3-5 years’ experience in clinical or community resource settings; care coordination and/or case management experience desirable
Experience partnering with an interdisciplinary healthcare team
Excellent interpersonal skills (strong written and verbal communication)
Experience utilizing an Electronic Medical Record
Ability to apply decisive, sound clinical judgment for cases with varying complexity
Experience with Patient-Centered-Medical Home desirable
Education & Certifications Licenses / Certifications: as applicable
Physical Requirements M - Medium Work: Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; requires frequent walking, standing or squatting.
For disease-specific care programs refer to the program-specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements. Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.
Pay Range $29.81 - $52.88
Location Massena, 13662
The listed base pay range is a good faith representation of current potential base pay for a successful full-time applicant. It may be modified in the future and is eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.
Equal Opportunity Employer Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.