RN Transitional Care Coordinator

Job Description Summary

The RN Care Coordinator works under the general supervision of Manager of Care Progression to coordinate care to specific at risk patient populations within the South Shore Health system of care. This System role works in close collaboration with the population health, innovation, and care progression teams. This role works with patients, families, and caregivers; as well as other members of the health care team; to deliver clinically-based, goal oriented Care Coordination aimed at engaging patients in chronic disease management activities, and reducing risk for hospitalization and/or re-hospitalization, and overall total cost of care.Central to the role of the RN Care Coordinator is a commitment to coaching patients to improve their health behavior to attain their health-related goals. This role is responsible for patient outreach telephonically, in person, and utilizing various technology platforms and tools based on patient eligibility. As a team member, the RN Care Coordinator must possess excellent communication skills, both written and verbal, and an ability to listen and be assertive as required. An ability to work independently is essential. The RN Care Coordinator works collaboratively with interdisciplinary staff internal and external to the Organization. The RN Care Coordinator participates in quality improvement, research and evaluation processes related to the management of patient care and population health strategy.

Job Description


Job Responsibilities:

1) Navigation and Care Coordination
a. Works within risk stratification methodologies to outreach and engage eligible patients into defined Care Programs.
b. Connect with risk stratified or referred patients in acute care, primary care and community settings to represent innovation programs and assist to develop initial care plan.
c. Identify and help to coordinate patient engagement into Transitional, Complex and Advanced Illness and other Care Management programs as appropriate.
d. Craft patient centered care plans based on evidence -based best practices for chronic disease management and transitions of care, with clearly outlined programmatic goals for care.
e. Identifies barriers and gaps in care and incorporates these into patient centered care planning.
f. Participate in weekly team care coordination reviews.
g. Provide Care Coordination follow up for panel of patients with intervention including referrals to community programs (MOW, Elder Services, Social Work, Behavioral Health, DME, home o2, etc.)
h. Patient outreach in person, telephonically, virtually. Conducting home visits as needed.
i. Communicates plan with physician, unit based case management team, patient, Care Plan Partner, PCP, and health care team.
j. Assist patient and Care Plan Partner, by incorporating shared decision making, motivational interviewing, and coaching strategies, to actively engage in self care and behavior modification in pursuit of enhancing the patient's personal level of health.
k. Explores and coordinate referrals to other programs as identified as eligible, to include VNA Care, Skilled Nursing Facility care, Palliative and Hospice care, elder services, senior care options and commercial payor programs.
l. Includes documentation to support referrals to SNF, acute rehab, home care, outpatient community clinics, etc.
m. Documents meetings with patient, family, physician across the continuum.
n. Re-evaluates and adjusts care plan accordingly across the continuum.
o. Maintains departmental productivity measurements.
p. Directs department activities in a manner consistent with organization-wide programs/procedures.
q. Follows department policies and procedures that reflect the organization's standards.
r. Evaluates the effects of case management on the targeted patient populations.

2) Education
a. Support reinforcement of education regarding programs with care management colleagues, health system providers and PCPs
b. Work closely with leadership and training on program changes, updates.
c. Contribute to the overall development of standard educational tools supporting chronic disease management.

3) Safety Awareness - Foster a "Culture of Safety" through personal ownership and commitment to a safe environment.
a. Verifies the patient using two unique identifiers.
b. Complies with the current CDC hand hygiene guidelines through proper handwashing, as observed by the nurse manager and peers.
c. Makes appropriate use of personal protective equipment at all times.
d. Adheres to universal precautions.
e. Safeguards the privacy and security of patient information. The employee complies with policies and procedures relating to SSH's privacy and security programs.

4) Professional Development
a. Uses the SBAR method to communicate with internal and external care providers.
b. Establishes and maintains effective communication with all community providers.
c. Assumes overall responsibility for professional development by incorporating evidenced-based practice, research, and performance improvement initiatives as a part of ongoing nursing practice.
d. Maintains current knowledge/certification licensure and is able to produce evidence of continued education in the field.
e. Pursues professional development. Will need to pursue ACM / CCM certification in 2 years of hire if does not already have.
f. Maintains current knowledge of case management, utilization management, discharge planning, as specified by federal, state, private insurance guidelines.
g. Maintains a working knowledge of the resources available in the community for patients/families.
h. Maintains current nursing licensure CEU credits, case management certification CEU's.
i. Complies with the mandatory education requirements.

5) Technology and Learning
a. Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.
b. Embraces technological advances that allow us to communicate information effectively and efficiently based on role.
c. Able to navigate multiple technology platforms to support work; to include Epic Clin Doc, Ambulatory Healthy Planet module, Epic Care Link, My Chart, Patient Ping, Arcadia, Tiger Connect, Zoom, Jabber, and Outlook.
d. Must have a smartphone mobile device available for business use which can support Tiger Connect communications at all times during work day

Job Requirements:

Minimum Education:

BSN required, Masters of Science in Nursing Preferred

Minimum Work Experience:

5-8 yrs: Med/Surg/Critical Care/Home Care RN preferred.
Experience in community care settings/ VNA preferred.
Experience with motivational Interviewing, patient education/engagement and population health management preferred.

Required Licenses / Registrations:

RN - Registered Nurse

Required Certifications:

ACM - Accredited Case Manager or CCM - Certified Case Manager within two years of hire.

Knowledge, Skills and Abilities:

Seeking highly motivated, tech-savvy, energetic and experienced clinical nurse case manager. This individual should have skills in the following areas: customer service, communication, technical platforms and mobile applications, strong interpersonal skills, care planning, care management and utilization. Bilingual (Spanish) preferred.
Demonstrates flexibility via an ability to adapt to changing priorities and regulations.