Overview RN Care Coordinator Pre-Post Natal - Care Transformation - FT - Day at Stormont Vail Health
The Care Coordinator serves in an expanded nursing role to collaborate with patients and their health care team including Primary Care Providers, specialists, and hospitals to provide a model of care that ensures the delivery of quality, efficient and cost-effective healthcare services across the continuum. The Care Coordinator functions as a coordinator of patient care, assesses, plans, implements, monitors, and evaluates all options and services with the goal of optimizing the patient's health status. The Care Coordinator integrates evidence-based clinical guidelines, preventative guidelines, protocols, and other metrics in the development of transitions of care plans that are patient-centric, promoting quality and efficiency in the delivery of healthcare for the targeted high-risk population. The Care Coordinator monitors patients across the health continuum with a focus on effective and safe transitions through the healthcare system with a goal to optimize resources and reduce avoidable readmissions back to acute care. The Care Coordinator manages performance feedback metrics to further refine the care model to maximize clinical, quality, and fiscal outcomes for the targeted population. The delivery of professional nursing care at Stormont-Vail HealthCare is guided by Jean Watson\'s Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization.
Responsibilities
Collaborates with specialty, primary care, social work staff, and other care team members to ensure optimal care coordination for the patient.
Serves as the point of contact for their patient population, or the care team to coordinate/manage health needs.
Initiates communication with patients upon learning they have been identified as high risk / targeted population.
Pulls data from multiple systems and merge together to create a complete performance picture related to targeted populations. Implements interventions based on data and established guidelines. Monitors data for trends and individual outliers. Analyzes data for process improvement opportunities to impact patient outcomes.
Optimizes patient care transitions by: collaborating with inpatient teams to support discharge plans; coordinates post-hospitalization care and discharge planning; ensures collaboration with primary care, social work & PCP care manager, other care team members, and community supports to ensure optimal care coordination for the patient.
Guides patients through the health care system; facilitates interaction and communication with health care staff providers; provides disease/treatment specific education to both patients and families; oversees scheduled appointments; oversees patient testing and admissions; reviews patient records; documents medical information using the appropriate forms and/or electronic applications; collects and tracks data related to targeted populations.
Participates in system wide/department patient care quality improvement activities and standards development; works with cross-functional teams to define analysis needs and propose solutions.
Appropriately delegates tasks and duties in the direction and coordination of health care team members, patient care, and department activities in accordance with the Kansas State Nurse Practice Act.
Qualifications
Education Qualifications – Bachelor\'s Degree of Science in Nursing (BSN) Required
Experience Qualifications – 2 years Nursing experience in an acute or ambulatory setting. Required; Case/care management experience preferred
Skills And Abilities – Demonstrates prudent professional and clinical judgement, effective problem solving skills, critical thinking, excellent organizational and interpersonal skills, creativity, flexibility, and the ability to multi-task. Ability to be self-directed, work autonomously, and function effectively in a fluid, dynamic environment. Strong communication and collaboration with diverse teams.
Licenses and Certifications – Registered Nurse - KSBN Required; Driver\'s License with clean MVR; Basic Life Support (BLS) Required within 90 days of hire.
What you will do
Collaborates with specialty, primary care, social work staff, and other care team members to ensure optimal care coordination for the patient.
Serves as the point of contact for their patient population, or the care team to coordinate/manage health needs.
Initiates communication with patients identified as high risk or targeted population.
Pulls data from multiple systems, merges data to create a complete performance picture, implements interventions based on data and guidelines, and monitors data for trends/outliers to drive improvements.
Guides patients through the health care system, provides education, oversees appointments and testing, reviews records, and documents information in electronic systems.
Participates in quality improvement activities and supports cross-functional teams in analysis and solution proposals.
Travel
50% Driving between facilities.
Remote Work Guidelines
Hybrid/Remote work with requirements for secure, private workspace and reliable internet access as per policy.
Equal Opportunity
Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. Retaliation is prohibited against anyone who files a claim of discrimination or opposes discriminatory acts.