RN - Transitional Care Coordinator-Jeff Hwy

Job Overview: This role manages identified complex/catastrophic patients attributed to the organization and its Network of partner providers. It uses the case management process to assess healthcare needs, identify barriers to care, develop comprehensive treatment plans with specific goals, implement plans in collaboration with the PCP team and other providers, negotiate and coordinate services, monitor and evaluate effectiveness, and modify plans as needed. This position is an integral part of the multidisciplinary care team and coordinates care among multiple providers, patient caregivers, community services, payors, and others to ensure seamless service delivery throughout the continuum of care. Education Graduate of an accredited school of nursing. Work Experience Required: 3 years of experience in a clinical setting; experience documenting in an electronic medical record and using Microsoft Office; experience working in a multidisciplinary team environment. Preferred: Bachelor’s degree in nursing. Preferred: Experience in case management, care coordination or disease management. Certifications Required: Current Registered Nurse (RN) License in the state of practice. Preferred: Certification as a Case Manager (CCM). Knowledge, Skills, and Abilities (KSAs) Proficiency in using computers, software, and web-based applications. Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals. Excellent knowledge of managed care, CMS, Medicaid, and other regulatory standards/requirements; ability to use community resources and other resources to facilitate patient care throughout the continuum. Good organizational and time management skills and ability to be self-directed and demonstrate good judgment. Job Duties Collaborate with members of the health care team, the patient, and patient’s caregiver(s) to develop and implement a coordinated treatment plan across the continuum. Assess patients for social determinants of health that may create barriers to care and include SDOH in the plan; refer to Social Work or Community Health Worker as appropriate. Use the case management process to develop comprehensive cost-effective plans of care for patients in care management. Collaborate with the multidisciplinary team, Primary Care Provider, and other appropriate care providers to facilitate appropriate care and treatment. Coordinate referrals and appointments with members of the care team. Provide in-depth disease-based patient education and formulate collaborative action plans with patient/caregiver to achieve agreed-upon goals for self-management and improved health status. Provide community resources to patients, families, and/or caregivers to avoid or reduce hospital admissions through telephonic and face-to-face contact. Identify quality issues that may adversely affect patient outcomes and submit to department leadership. Perform other related duties as required. Physical and Environmental Demands Light work: Exerting up to 20 pounds of force occasionally, up to 10 pounds of force frequently, or a negligible amount of force constantly. Work may involve walking, standing, sitting, pushing, pulling, and handling materials. Operations involve exposure to blood, body fluids, or tissues and potential communicable diseases. Occupational risk of exposure to hazardous medications or waste may exist. EEO Statement Ochsner is an equal–opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. #J-18808-Ljbffr Ochsner Health