Continuing Care Coordinator RN

Continuing Care Coordinator RN

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation's largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 138 hospital-based locations, in addition to its home-based services and virtual care offerings.

The posted compensation range of $39.18 - $58.28/hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

With guidance from the local market leadership, the RN Continuing Care Coordinator works collaboratively with physicians, staff and other health care professionals within his/her clinical setting to maintain and improve quality and sustainability within the local market network, this work includes:

• Chronic Disease ManagementDevelops a plan of care based on a nursing assessment of the patient and their individual circumstances. The plan of care will include patient and caregiver education as well as coordination and collaboration of care with an interdisciplinary team working with that patient. The RN will also be responsible for monitoring the patient's progress with the care plan.
• Practice Pattern ManagementReferral Management, based upon local program criteria.
• Performance Data InterpretationParticipates in development of workflows and audits.
• Evidence-Based Metric (EBM) guidelines / care plansImplements and hardwires different EBM guidelines in the ambulatory setting as well as facilitating seamless transitions of care between clinic and post-acute settings and between clinic and other health professionals.

Essential Key Job Responsibilities

• Assessment
• Works with "at risk" patients and families on self-management support including: Performing individual needs assessment, care plan design, education, documentation, implementation, and evaluation of outcomes according to state and national guidelines, policies, procedures, and protocols as required. Following evidence-based care pathways. Coordinating care across multiple provider sites and interdisciplinary teams. Working with patients to create a plan of care for health behavior change: Assessing and working on the patient's readiness to change, the importance of change, and confidence in ability to change. Helping the patient to identify and overcome barriers. Setting short and long-term goals for self-management of chronic disease, empowering the patient, family and /or caregiver to achieve maximum levels of wellness and independence. Referring to appropriate services when applicable including but not limited to community resources and services to address the established goals or desired outcomes.
• Anticipates and identifies variances in the care process related to those identified needs. Modifies plan of care to resolve unexpected care needs.

Leadership

• Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration, communication and coordination among all responsible parties of the multidisciplinary healthcare team striving to eliminate fragmentation, duplication or gaps in care.
• Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provides ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly. Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.

Critical Thinking

• Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible.
• Monitors member's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments.
• Reports to the Care Coordination Manager or Director for Quality and Utilization regarding member status and identifies any potential risk management.

Relationships

• Leads efforts to optimize care coordination across the care continuum, building and maintaining positive relationships with the healthcare team.
• Assumes responsibility, authority and accountability for patient load, assisting other coworkers when requested or as the need arises.
• Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner.

Baylor St. Luke's Medical Center is an 881-bed quaternary care academic medical center that is a joint venture between Baylor College of Medicine and CHI St. Luke's Health. Located in the Texas Medical Center, the hospital is the home of the Texas Heart Institute, a cardiovascular research and education institution founded in 1962 by Denton A. Cooley, MD. The hospital was the first facility in Texas and the Southwest designated a Magnet hospital for Nursing Excellence by the American Nurses Credentialing Center, receiving the award five consecutive times. Baylor St. Luke's also has three community emergency centers offering adult and pediatric care for the Greater Houston area.

Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit https://www.commonspirit.careers/benefits.

Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.

CommonSpirit Health is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here [PDF].

CommonSpirit Health will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health participates in E-Verify.