Care Coordinator, RN

Job Description

Job Description

Description:

RN Care Coordinator 

The RN Care Coordinator at TRIARQ Health is central to the patient experience, connecting patients with the right providers and resources while ensuring clear, consistent communication throughout the patients’ care journey. This position requires development and maintenance of successful relationships with hospital case managers, discharge planners, home health/skilled nursing administrators, physicians and key healthcare decision makers. This position requires collaboration with all stakeholders to develop and improve care planning and care management processes across our network of partner practices and preferred providers. It also requires collaboration with a multi-disciplinary team to provide patient education, communication with health care providers, and coordination with the facilitation of services within an episode of care. The RN Care Coordinator will have the opportunity to make a difference in reducing health care costs and increase the value of health care to patients and payers.

Responsibilities:

· Coordinate and support patients following surgery and/or following diagnosis of certain conditions, delivered in partnership with participating physicians and aligned with physician-directed care plans (Medicare Advantage, BPCI, Urology Trend and MSK Trend Surgical programs).

· Provide general education, care navigation, and advocacy support, including helping BCBSM members understand available care options the member should discuss with their provider, and connecting patients to appropriate providers or resources to obtain the clinical evaluation or assistance they need (MSK Trend Non-surgical program).

· Provide support to care coordinators and clinical teams embedded within our clinically integrated network and partnered orthopedic and urological practices.

· Provide professional nursing insight to the patient throughout the continuum of care, including pre-operative and post­operative therapy, SNF, and Home Care Services.

· Create and promote adherence to a care plan, developed in coordination with the patient, physician, and family/caregiver(s).

· Engage in ongoing evaluation and revision of plan of care as determined by patient's health status. 

· Communicate changes to all providers and multi-disciplinary care team members involved in the patient's care.

· Utilize the care management and referral platform (QPathways) to document patient interactions, track care coordination activities, and support continuity of care.

· Collaborate effectively with the patient’s health care team (physicians, nurses, discharge planners, referral coordinators, surgical schedulers, etc.) to establish an optimal transition plan to the most appropriate PAC (post-acute care) setting and ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services.

· Monitor PAC utilization to identify potential overutilization and support appropriate, cost-effective care delivery.

· Conduct status check-ins for surgical and non-surgical patients in accordance with predefined care plan criteria and processes.

· Engage patients with appropriate care coordination and education via multiple channels (phone, text, email) in response to outreach campaigns.

· Coordinate referrals between primary care physician (PCP), physical therapy (PT) providers, and Orthopedic Specialists.

· Participate in cross-training and maintain expertise across multiple contracts and clients to support coverage needs across the organization. 

· Manage an independent workload while maintaining expected productivity.

· Review outcome reports and other reports as needed to assist with the identification of opportunities for improvement and program development.

· Attend departmental and organizational meetings as requested.

· Adhere to departmental and organizational policies and procedures.

· Maintain confidentiality of all PHI information in compliance with HIPAA, federal and state regulations and laws.

· Perform other duties and responsibilities as required, assigned, or requested.

Work Environment: Remote Setting

Reports to: Director of Care Management and Member Navigation

Job Type: Full-time

Requirements:

 

Skills & Additional Requirements:

· 1-3 years of clinical care management or patient care experience required.

· Active, unrestricted clinical license required in state of hire – Registered Nurse

· Excellent documentation skills as well as strong interpersonal and communication skills (both verbal and written).

· Competent computer skills with proficiency in Microsoft Office products and the ability to learn new technical skills.

· Ability to use multiple integrated technology platforms and virtual care coordination tools simultaneously.

· Ability to organize and prioritize workload with effective time and task management skills in achieving program initiatives and priorities.

· Ability to be a proactive team player and collaborate with coworkers and stakeholders.

· Ability to work independently in a fast-paced environment and successfully complete multiple tasks with little or no supervision.

· Ability to use good judgment and problem-solving skills, as well as effectively respond to difficult situations, and resolve conflicts.

· Ability to prioritize daily workload and act as a self-starter.

· Ability to act in a way that is passionate, trustworthy, and empathetic when working with clients, providers and patients. 

· Ability to build relationships with different types of people, including clients, organization members, and all types of health care providers.