Overview
Continuing Care Coordinator RN — CommonSpirit Health
Job Summary and Responsibilities
You must reside in the Greater Houston TX area.
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 Management—Develops 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 Management—Referral Management, based upon local program criteria.
Performance Data Interpretation—Participates in development of workflows and audits.
Evidence-Based Metric (EBM) guidelines / care plans—Implements 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 readiness to change, importance, and confidence in ability to change.
Helping the patient 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 community resources.
Anticipates and identifies variances in the care process and modifies the plan of care accordingly.
Leadership
Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration and coordination to eliminate fragmentation, duplication, or gaps in care.
Designs plans for data gathering and analysis of baseline and ongoing success; supports practitioners in collecting, interpreting, and communicating data; works toward reducing preventable admissions and duplications.
Critical Thinking
Assists patients or caregivers with navigating the healthcare system to minimize fragmentation, obtain timely care, and access appropriate providers and procedures.
Monitors scheduling compliance and identifies patterns of nonadherence; coordinates scheduling of needed appointments.
Reports to the Care Coordination Manager or Director for Quality and Utilization regarding member status and risk management.
Relationships
Leads efforts to optimize care coordination across the care continuum and maintains positive relationships with the healthcare team.
Assumes responsibility and accountability for patient load; assists others when needed.
Resolves conflicts positively and professionally.
May also be required to meet patients and/or family members in the community, at home, or other locations. Must be able to assess the environment for safety for self and patients and escalate concerns to the Medical Social Worker, Licensed Social Worker, or program manager as appropriate.
Concerns or complaints
Research and recommend appropriate follow-up and/or corrective measures
Identify opportunities to achieve department process excellence through data analysis and interdisciplinary team involvement
Department audits
Assist with audits at the direction of the manager
Consolidate audit results and provide analysis
Day-to-day operations: assist with hiring by organizing peer interviews at the direction of the manager
Work with management to ensure daily performance of staff supports effective and safe patient care and department operations
Mentor new employees, meeting weekly with the employee and/or leadership to track progress
Identify and participate in projects to improve team performance
Design plans for data gathering and analysis, providing ongoing support to team members in collecting and interpreting data
Team conferences and interdisciplinary meetings; initiate patient care conferences when needed
Committee participation outside of operational departmental work
Job Requirements
Required Education And Experience
Associate degree in Nursing
Two (2) years relevant experience or advanced degree
Preferred
Bachelor Science Nursing degree
3-5 years relevant experience
Case Management experience
Required Licensure and Certifications
Texas RN: TX or Compact
Required Minimum Knowledge, Skills, Abilities and Training
Ability to handle multiple priorities with strong attention to detail.
Strong organizational (time management) and interpersonal skills.
Effective written and verbal communication; proficient in email, Microsoft Excel and Word.
Knowledge of information technology to evaluate care effectiveness.
Ability to work autonomously within a matrix environment.
Collaborates with interdisciplinary partners in managing identified patient populations.
Implements program goals, including high-priority case management redesign efforts.
Works with community resource partners and post-acute care providers to ensure seamless transitions.
Assesses, reports, and communicates patient status to team stakeholders.
Excellent computer skills and ability to learn new systems.
Where You'll Work
Baylor St. Luke’s Medical Center is an 881-bed quaternary care academic medical center in the Texas Medical Center. It is a joint venture between Baylor College of Medicine and CHI St. Luke’s Health, located in Houston. The hospital has been designated Magnet status for Nursing Excellence and offers multiple care centers in the Greater Houston area.
Pay Range
$39.18 - $58.28 /hour
Seniority level
Not Applicable
Employment type
Full-time
Job function
Health Care Provider
Industries
Wellness and Fitness Services
Hospitals and Health Care
Medical Practices
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