RN - Outpatient Care Coordinator

Carle Foundation

Job Description

$5,000 sign-on bonus and

$5,000 relocation (for greater than 100 miles) or

$2,500 relocation (for greater than 50 miles)

for nurses with 1 or more years experience - External Applicants Only
The Care Coordinator RN is responsible for providing seamless, coordinated care across the continuum for patients identified as high risk. Responsibilities include: assessing, utilizing protocols, planning, implementing, educating/coaching, referring, coordinating/facilitating medication management, monitoring, evaluating, communicating, collaborating, and negotiating with patients, caregivers, and providers to assure the patient is receiving the right care, in the right place, at the right time.

Bachelors Nursing or BSN obtained within five (5) years of hire.

Registered Nurse (RN) Illinois and Basic Life Support (BLS)

2 Healthcare/Medical - Nurse: Registered Nurse. Relevant clinical experience and current knowledge of healthcare trends, related to emerging models of population health management. Knowledge of chronic conditions, evidence-based practice, care coordination, care management, and psychosocial and behavioral factors affecting health. Familiarity with patient-centered care models and techniques. Ability to prioritize and manage multiple high-risk, complex patients. Demonstrated ability to solve multi-faceted problems in a fast-paced, high stress environment. Demonstrated ability to multi-task and interact with care team across the continuum in a proactive, positive, outgoing manner. Must possess excellent verbal, written, organizational and critical thinking skills. High comfort level with EMR is essential. Demonstrated commitment to complex patients, to caregivers and to the organization.

Essential Functions:

Assists in conducting health risk assessments (HRAs) and reviews of patient records and/or claims analysis to identify care management and care coordination services
Collaborates with other Case Managers, when applicable, to ensure smooth handoffs of patients from case manager to case manager and to all involved caregivers across the continuum
Provides and manages care management and care coordination services in a timely, efficient, and cost-effective manner to meet patient-specific clinical and social needs
Assists in developing patient care plans and care goals
Monitors patient progress in relation to care plans and expected outcomes
Actively engage as an integral, collaborative member of the patient's care team
Communicates with and disseminates information to the patient, PCP, and other care team members to ensure consistent, seamless, and coordinated care
Facilitates care coordiation for the patient across the care continuum, ensuring that the patient is receiving the highest level of quality
Advocates consideration of all options available to ensure quality of care in the most cost-efficient manner
Refers patients to appropriate and available resources to meet identified needs
Supports processes to ensure that appropriate authorizations, referrals, and payor requirements are obtained and met to allow patient care
Actively involve patients/caregivers in their healthcare and encourage shared decision making.
Documents required clinical, social, financial, or other information using appropriate systems
Manages a case load of up to 100 high-risk patients
Participates in continuous quality, performance, and outcome assessment and improvement initiatives to ensure the improvement of care management/care coordination and available clinical and social support services
Assists in the development of care management tools needed to support the patient population
Provides education to patients and caregivers to optimize level of self-care
Addresses gaps in care per best practice guidelines, HEDIS measures and clinical guidelines as appropriate
Meets the patient face to face when necessary which may include: in the home, in the hospital, or in an ambulatory setting
Completes comprehensive assessment of high risk patients within the health system
Works closely with the primary care provider and interdisciplinary team to create a plan of care for each patient
Completes patient handoffs during appropriate patient transitions of care
Communicates telephonically and in person with paneled patients to ensure follow up and understanding of plan of care
Documents within EPIC using the department specific templates to ensure minimum documentation standards are met.

Employment Type

Full - Time

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