The Care Coordinator- RN, in partnership with the family and interdisciplinary care team, promotes timely access to care, ensures comprehension of the medical plan by the patient and family, and promotes continuity of care through intensive care planning and ongoing communication with the family and care team. By providing comprehensive, culturally sensitive care coordination, the patient and family will have increased satisfaction and improved clinical outcomes.
Home visits are NOT required for this role.
The following describes the basic position duties that an employee MUST be able to perform for this role. This information is intended to be descriptive of the key responsibilities of the position. The list of essential functions below DOES NOT identify all duties performed by any single person in the position.
Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field
Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market
Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements
Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information
Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies
Works independently, receives minimal guidance
Explains difficult or sensitive information; works to build consensus
JOB SPECIFIC RESPONSIBILITIES:
Clinical Management: lead daily huddles and participate in setting priorities for patient needs. Confirm treatment plan and intended goals. Monitor the patient's progress toward the desired outcome. Collaborate with physicians to establish treatment milestones. Facilitate referrals to the appropriate areas to expedite care, treatment and services. Secure clinical resources essential to achieve the desired outcomes. Collaborate with physicians, patients and families and nurses to identify and address any probable care needs. Participate in the development, implementation, evaluation and ongoing revision of the plan of care, clinical pathways and initiatives to improve quality and continuity. Support the co-management among all providers by providing timely communication and integration of information into the care plan.
Communication: Provide ongoing communication with patients and families, physicians, interdisciplinary team members and payers to facilitate coordination of clinical activities and to enhance the effect of a seamless transition across the continuum of care. Partner with families to ensure understanding of payer guidelines and to arrange referrals. Serve as the contact point, advocate, and informational resource for family and community partners/payers. Demonstrate comprehensive, patient/family-centered, culturally sensitive, care coordination services.
Resource Management: Identify opportunities for improvement related to delivery of care, delays and potentially avoidable days through consistent data capture. Intervene with ancillary department leadership when timely service is critical to the patient's immediate needs. Interact with patients and physicians to explore the most appropriate setting to meet the patient needs. Research and link resources and services for the patient and family. Coordinate care among all involved organizations(schools, home health, etc.) by facilitating team conferences as needed.
Medical Documentation: collaborate with payers to be knowledgeable regarding documentation. Ensure all documentation meets regulatory and payer requirements. Collaborate with the physicians, offer suggestions for more accurate and complete documentation. Share written information with physicians to inform and educate on the dimensions of accurate documentation.
Process and Performance Improvement: Work collaboratively to define and study areas of inefficiency and participate in process improvement projects. Coordinate efforts to gain patient/family feedback (advisory board, surveys, etc.) and intervene to address any identified needs. Offer outreach to community partners to provide continuity in care and improve outcomes for the patient and family.
Transition Planning: Collaborate with team members to develop a transition plan appropriate to the patient's needs. Serve as consultant and educator to patient and family regarding recommendations. Convene and conduct interdisciplinary conferences to solicit input from clinical team members on selected patients. Serve as liaison to community resources in an effort to meet patient and family needs.
Direct - Indicates that the person in the position directly provides care, treatment or services to the patient. Ex: Nurses, Physical/Occupational Therapists, RCPs.
Case Management, Utilization Review, Home Health Care, Discharge Planning, Pediatrics preferred.
At least 3 years relevant experience required.
Four-year Bachelor's degree or equivalent experience required.
LICENSES and CERTIFICATIONS:
Registered Nurse, current license to practice professional nursing in the state of Texas required.
Certified Case Manager preferred.
Specific Knowledge, Skills and Abilities:
Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
Develop and use collaborative relationships to facilitate the accomplishment of work goals.
Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
and families begin to trust you and think of you as a family member. It feels less medical to them because they are at home. I really do love my job and I am super proud to work here and be part of such a wonderful team.
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