RN Care Coordinator

RN Care Coordinator

The RN Care Coordinator will work as part of a multidisciplinary healthcare team supporting patients in the outpatient setting. In collaboration with the patients healthcare team, the RN Care Coordinator will focus on the coordination of care for targeted high risk patient populations to facilitate seamless, safe and effective transitions of care. They will utilize appropriate resources to promote quality, cost effective outcomes, as the patient transitions through the healthcare continuum.

Primary Position Responsibilities:

• Provide outreach to identified patients, providing assistance to address social determinants of health, barriers to care, education on disease state and medications, coordinating care needs with primary care, specialty care and ancillary services.
• Develop constructive relationships with local hospitals and subacute care facilities admission offices, case managers, discharge planners, and emergency department (ED) contacts.
• Work to develop systems, processes and initiatives to engage these entities in relevant care management activities with each patient to ensure that necessary post-discharge and on-going medical needs are met.
• Monitor to ensure care is coordinated with home care agencies, specialists, or other resources as follows: Ensure Transition Care Management (TCM) visits (with Specialist or Primary Care Provider) are completed within CMS guidelines. Facilitate follow-up visits with appropriate specialists and review recommendations with complex patients; Communicate with and educate patients (and/or their caregivers as appropriate) about new diagnoses, medications, and discharge instructions. Monitor that appropriate home care, hospice care, and other ancillary services (durable medical equipment, infusion services, etc.) are in place. Utilize required software technologies, including but not limited to the EMR to effectively communicate with interdisciplinary healthcare teams. Assist with review and analysis of internal and payor reports to target specific populations and close gaps in care and optimize outcomes. Facilitate transportation services for specified individuals based on policies and protocols. Work collaboratively with all members of the team, being available to attend any scheduled or ad-hoc meetings or participate in committees or work groups as requested.

Work Contact: Hunterdon Health Case Management/Social Work Team, Hunterdon Home Health/Hospice Team, HHP Care Coordination Team, HMG Care Coordinators, Independent Practice Care Coordinators, HHP Primary Care and Speciality Care Practices, Insurance Plans Case Management Teams, Sub Acute Facilities, others as determined based on job functions.

Qualifications:

• Minimum Education Required: BSN or RN with strong applicable experience including home health and/or acute care setting and/or holds a certification in the field such as Certified Case Manager (CCM).
• Minimum Years of Experience Required: Three years of acute, hospital based, direct patient care experience. Applicants with 3 years of home health or subacute nursing may also be considered.
• Preferred: Five years of acute, hospital based, direct patient care experience and care coordination or Case Management experience.
• License, Registry or Certification Required: Current NJ RN licensure
• Preferred: Certification in specialty (Case Management, Care Coordination)
• Knowledge, Skills and/or Abilities Required: Strong verbal, written, organizational and interpersonal communication skills. Ability to develop and maintain collaborative relationships with the interdisciplinary team and co-workers. Comprehensive assessment and discharge planning. Demonstrate knowledge-base in patient care evaluation and assessment, patient/family/caregiver engagement, insurance/benefits for services, community resources and, research and evaluation techniques for quality improvement. Ability to learn current software applications and new technologies.

Hiring Salary: $70,000/yr