RN Care Coordinator - Skilled Nursing Facility

RN Care Coordinator - Population Health Systems Of CareJoin our team as a full time days RN Care Coordinator - Population Health Systems of Care, INTEGRIS Health, Oklahoma City.Get to know your team:INTEGRIS Health, Oklahoma's largest not-for-profit health system, is seeking a dedicated caregiver to join us in our mission to partner with people to live healthier lives.Benefits of being an INTEGRIS Health caregiver include front-loaded PTO, medical benefits through the extensive INTEGRIS Health network, financial assistance for continued education, 24/7 mental health support and more.Take the first step toward growing your career by joining us.QualificationsCurrent licensure as a Registered Nurse (RN) in the State of Oklahoma or current multistate license from a Nurse Licensure Compact (eNLC) member stateBachelors degree in Nursing preferredMinimum of 3 years recent clinical experience in a variety of clinical settingsMust obtain BLS within 90 days of hire and renew according to guidelinesCare Management or Care Coordination experience preferredExcellent interpersonal communication and collaboration skills.Computer experience required. Windows and Excel preferred.This job requires the incumbents to operate a INTEGRIS-owned vehicle OR personal vehicle (non INTEGRIS-owned) and therefore must have a current Oklahoma State Drivers License as well as a driving record which is acceptable to our insurance carrierResponsibilitiesThe RN Care Coordinator responsibilities include, but are not limited to, the following:Assess patients for clinical, psychosocial, financial and other factors that may affect the quality and health outcomes.Evaluates the potential impact of social determinants of health that may elevate the patient's risk in achieving optimal health outcomes.Collaborates with the care team to provide high quality, cost-effective, patient centered care.Provide patient education.Collaborate with patients/families/caregivers in goal setting, evaluates the level of understanding and engagement with the progress toward goals, and incorporates findings into the plan of care.Arranges services among community agencies, provider, patient/family/caregivers and others involved in the plan of care.Utilizes shared decision making with the patient/families/caregivers, develops a plan that is clinically appropriate and focused on the patient's care needs and goals for care and treatment plan that is consistent with patient choice and available resources.Identifies barriers to achieving recommended goals identified in the plan of care.Promote wellness and provide education regarding preventative care measures.Completed Transitional Care Management per departmental key process standard work.Identify root cause for readmission to include patient/ family/caregiver perspective and implement strategies to reduce future risk.Convey all necessary information for continuity of care and patient safety, verify receipt and provide a venue for additional questions and/or information requests/needs.Identify available community resources/potential partners and advocate for resolution of gaps in the available resources and processes.Support a mechanism to ensure a method of contacting the patient/family/caregiver within a timeframe appropriate to the site of care in order to validate the success of the transition and make their best effort to resolve any identified barriers to the plan of care.Documentation is included in the patient's medical record and readily accessible to all other care team members.Knowledgeable of and ensure compliance with the federal, state, local organization and accreditation requirements that not only impact their scope of services but affect their ability to advocate for the patient. Case Management organizational structure, staffing, policies and procedures must meet the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation.All disciplines function within the scope of practice as defined by state licensing regulations.Case Management adheres to organizational policies, rules and regulations to promote prevention of fraud and abuse.Reports to assigned Director or Manager.This position requires the ability to access and review external EMR platforms (e.g., hospital systems, skilled nursing facilities, home health agencies) to ensure accurate and timely information sharing, coordination, and documentation across the continuum of care.This position may have additional or varied physical demand and/or respiratory fit test requirements. Please consult the Physical Demands Project SharePoint site or contact Risk Management/Employee Health for additional information.Normal office environment. When working in clinical areas, potential for exposure to infections and communicable diseases, blood and body fluids, electrical equipment, chemicals. Must follow standard precautions.All applicants will receive consideration regardless of membership in any protected status as defined by applicable state or federal law, including protected veteran or disability status.About UsINTEGRIS Health mission: Partnering with people to live healthier lives. To our patients, that means we will partner to provide unprecedented access to quality and compassionate health care. To you, it means some of the state's best career and development opportunities. With INTEGRIS Health, you will have a genuine chance to make a difference in your life and your career. INTEGRIS Health is the state's largest Oklahoma-owned health system with hospitals, rehabilitation centers, physician clinics, mental health facilities and home health agencies throughout much of the state.Job InfoJob Identification 117398Job Category Registered NurseLocations Oklahoma City, OK, United States (Hybrid)Degree Level Associate DegreeAssignment Category Full-time regularJob Shift Day Job