Overview
Continuing Care Coordinator RN role at CommonSpirit Health.
Responsibilities
Chronic Disease Management—Develops a plan of care based on a nursing assessment of the patient and their individual circumstances, including patient and caregiver education as well as coordination and collaboration of care with an interdisciplinary team. The RN monitors 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 standardizes different EBM guidelines in the ambulatory setting and facilitates 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 of change, 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 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.
May also be required to meet patients and/or family members either in the community, at home, or other location. Must be able to assess the environment for safety for self and patients and escalate any concerns to the Medical Social Worker, Licensed Social Worker or program manager based on the situation.
Disclosure summary
The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.
Qualifications
Required Education And Experience
Associate degree in Nursing
Two (2) years relevant experience or advanced degree
Preferred
BSN 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 and interpersonal skills
Effective written and verbal communication; proficient in email and basic Microsoft Excel and Word
Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost)
Ability to work autonomously within a matrix environment without direct supervision
Manages and works closely with interdisciplinary partners in the management of identified patient populations
Implements program goals including high-priority case management redesign efforts to improve performance
Collaborates with Community resource partners, Post Acute Care Providers, and other clinical staff to ensure seamless transitions of care
Assesses, reports, and communicates patient status to stakeholders
Excellent computer skills and ability to learn new systems
Pay Range
$39.18 - $58.28 /hour
Employment type
Full-time
Job function
Health Care Provider
Industries
Wellness and Fitness Services, Hospitals and Health Care, and Medical Practices