Job Description
Overview
The Care Coordinator RN is responsible for providing care management and population health services to patients within the assigned region. Primary target populations include those at high risk and vulnerability at times of transition between care settings. Cross-continuum care managers create longitudinal, personalized care plans for patients/family/support system, collaborate with and coordinate the efforts of care across the continuum. Consistently using data analytics to manage the health of populations to improve patient access to care, reduction in cost of care, and improved clinical outcomes.
Qualifications
Certifications: Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)Illinois Department of Financial and Professional Regulation (IDFPR); Basic Life Support (BLS) within 30 days - American Heart Association (AHA)American Heart Association (AHA), Education: College Diploma: Nursing; Bachelor's Degree: Nursing, Work Experience: 2+yrs Nursing
Responsibilities
Essential Functions
Conducts in depth assessments of patient/family needs by coordinating input from all health professionals and formulating a documented plan assuring continuity of care for at risk patient populations. Holistic health care assessment includes: health risks assessment, patient preferences and goals, health literacy, patient engagement level, patient confidence level to perform self-management, impact of chronic health conditions and comorbidity, and social determinants of health.
Delegates care based on the situation while assuming accountability for patient outcome. Supports assistive personnel; serves as a resource and holds care team accountable to complete delegated tasks. Develops shared care plan and document on the Common Care Plan to allow access by all care team members across the care continuum. Performs outreach utilizing best practices to engage appropriate patients for care management.
Advance Care Planning- Connects patient and surrogate decision maker to ACP facilitation process. o Ensure that Advance Care Planning documents are stored and available within the EHR
Medication Management -Reconcile discharge medication orders, medication orders by specialists and PCP. Collaborate with PCP/Interdisciplinary team members on medication changes as needed. Ensure patient understanding of any medications to stop taking or initiate. Be clear to patients why medications were discontinued.
Psycho-social support ▪ Identify complex behavioral or social needs; make appropriate referrals (SW, BH consultants, and community agencies/partners) through collaboration with physician (hospitalists/PCPs/specialists), leads and coordinates activities of interdisciplinary treatment team to evaluate progress, identify barriers, and opportunities to improve care.
Coordinates and manages transitions of care across the continuum to assure appropriate utilization of clinical and community resources.
Coordinate referrals processes from PCP to Specialty; Provides oversight if patient transitions to SNF and monitor progress throughout the patient stay in collaboration with Post Acute internal and external care partners. Uses technology platform(s) to monitor and act upon changes in condition as directed by the primary care provider. Ensure post SNF transition plan is completed for Post-discharge call and follow up appointment is scheduled with PCP. Coordinates access to resources and supports to achieve the goals of care such as specialists, homecare, palliative, hospice and other community services.
Initiates post transition phone calls to high risk / high vulnerability patients to assess self-management and to identify risk of readmission prior to their first appointment.
Participate in quality improvement processes such as Readmission Root Cause Analysis, ED, and inpatient Hospitalization utilization reduction and mitigation efforts.
Collaborates with the IP Team to align the appropriate resources and support systems to ensure successful transition to the outpatient setting. Ensure communication through warm hand off processes.
Patient Education - Assesses patient/family knowledge and confidence level of chronic disease self -management and refers to internal and external resources to mitigate identified knowledge gaps. Reinforces education regarding chronic disease self- management utilizing approved action plans, educational materials and best practice recommendations. Facilitates health and disease specific patient education utilizing Teachback methodology. Empowers patients and families through education and a trusting relationship to utilize healthcare resources appropriately minimizing unnecessary healthcare utilization.
Data Analytics- Identify appropriate risk stratification via EHR encounters or datasets to intervene as appropriate. Integrate patient registry, stratification and other tools/reports to identify patients who may be appropriate for care management.
Manages revolving patient panel of 100-125 patients, within the at-risk populations served, including management of patients with multiple co morbidities, high volume unnecessary ED utilization, and/or high risk for admission or readmission to a hospital setting.
Assists in the development of care management tools needed to support the patient population.
Works in collaborative partnerships with primary care providers and interdisciplinary team members across the continuum of care to create an individualized plan of care for each patient served.
Manages transitions across the continuum and ensures warm hand off occurs appropriately during transition periods with focus on warm hand off processes between interdisciplinary teams.
Performs telephonic and in person touch points with paneled patients to ensure patient compliance in follow up and understanding of plan of care.
About Us
Find it here.
Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.
Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.
Compensation and Benefits
The compensation range for this position is $33.11per hour - $53.88per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.