Job description
- POSITION SUMMARYThe Nurse Care Coordinator organizes team-based care planning to provide support and comprehensive health services to individuals, mainly focusing on individuals with higher risk and complex needs, through effective partnerships with patients, their caregivers/families, community resources, and their healthcare providers. Performs short term transitional care activities and longer-term care planning for complex patients through facilitation of a shared care plan across the continuum of care to achieve well-coordinated, timely, cost-effective, high-quality care that is patient and family centered.
- PRIMARY DUTIES AND RESPONSIBILITIES
- Manages a panel of active patients requiring complex care management and care coordination support
- Collaborates with the multidisciplinary team, including the patient and their family, to design and implement holistic individualized plans of care for patients enrolled in care coordination programs
- Communicates necessary and important information to physicians, supervisors, patients and staff
- Assess patient and family s unmet health and social needs as well as health literacy and identifies strategies to resolve needs
- Assesses and identifies strategies to improve the health literacy of the patient and their family/ home care givers as appropriate
- Promotes patient engagement in self-care management through use of strategies such as creating patient directed care plans and motivational interviewing
- Provides chronic disease self-management support and education for patient enrolled in care coordination programs. Educate patients and their home care givers on self-management activities, medications, community resources, and advanced care planning
- Provides care coordination support across settings and transitions of care including discharges from acute and post-acute settings, specialty settings and provider transitions
- Monitors patients adherence to plan of care and progress towards mutual goals in a timely fashion, facilitate changes and creates action plans as needed
- Monitors patient care to ensure the most effective use, or need of resources
- Addresses and works to resolve patient concerns or barriers to achieving personal health goals through health coaching, education and coordination of patient access to community resources, financial assistance, and other supports as appropriate
- Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time
- Facilitate patient access to appropriate medical, specialty providers, and community providers
- Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow up, consultation as well as integration of information into the care plan and EMR.
- Serve as a point of contact, advocate, and informational resource for patient, family, care team, payers, and community
- Utilizes IT population health tools to identify and manage patients requiring comprehensive care coordination support
- Promotes high standards of patient safety, quality, access and continuity of care in care management, care coordination, and related care activities
- Participates in care coordination department s quality improvement and program development activities
- Attends staff meetings and ongoing educational programs to maintain up-to-date knowledge of evidenced based clinical practice in care coordination, population health, the health care industry and organizational goals
- Maintains up-to-date professional licensure and certifications
- Maintains up-to-date personal knowledge of policy and procedural guidelines and professional scope and standards of practice
- Provides mentoring/coaching/ support of other population health and care coordination team members
- Acknowledges patient rights and always maintains patient confidentiality following all HIPAA and privacy guidelines, policies and regulations
- Employees are expected to work consistently to demonstrate and promote the mission, vision, beliefs, core values and standards of behavior of the organization
- Demonstrates dependability (e.g. on time for work, appointments, & scheduled meetings)
- Remains flexible and adapts to changes on the job during unexpected situations or changing conditions/environments
- Exhibits maturity and self-control, even in situations involving conflict or stress & handles in a professional manner
- Demonstrates honesty & integrity in all interactions with others and complies with legal and regulatory standards
- POSITION QUALIFICATIONS
- Education:
- Graduate of an accredited nursing program required.
- BSN or higher-level degree in nursing preferred.
- Licensure/certification:
- Current nursing licensure in the state of New Hampshire required.
- Registered Nurse Licensure in Massachusetts in addition to New Hampshire preferred.
- Specialty Certification i.e. ambulatory nursing, CCM, CCTM, Guided care, CHCQM preferred.
- Experience:
- 5 or more years nursing experience in acute, skilled nursing, community health and/or ambulatory setting required.
- 3 or more years experience in care coordination or case manager role in acute, skilled nursing, community health, and/or ambulatory setting preferred.
- Experience working with an ACO or value-based contracts preferred.
- Knowledge:
- Coordination of Community Health Services
- Care Planning
- Chronic disease management
- Confidentiality regulations
- Preferred:
- Medicaid/CFI applications
- Long term care planning
- Advanced care planning
- ACO and value-based contracts
- Health or LTC insurance
- Skills:
- Strong clinical nursing skill set
- Skilled use of PC applications such as Microsoft office programs (word, excel, PowerPoint, email)
- Communicate efficiently utilizing written, verbal and technology such as email, telephone and video calls
- Preferred:
- EPIC EMR experience
- Motivational interviewing
- Shared Decision Making
- Abilities:
- Organizational skills
- Time management
- Ability to multi-task and prioritize
- Ability to work independently and collaboratively
- Takes initiative to tackle important issues, problems and tasks proactively without needing supervision
- Strong interpersonal skills
- Strong customer service awareness
- Maintain confidentiality of all medical, legal and financial information
- Manage difficult situations
- Manage active case load of patients (approx. 100-150)
- Education:
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