RN Care Coordinator, Internal Medicine, Full Time, First Shift

Ambulatory RN - Care Coordinator

The Ambulatory RN - Care Coordinator is a vital member of the healthcare team responsible for ensuring seamless and high-quality care for patients in an ambulatory setting. This role involves both direct patient care and administrative responsibilities, with approximately 60% of time dedicated to patient-facing duties. The RN will support ambulatory physician clinics by seeing patients with complex and chronic disease that require additional support during outpatient visits. They will be involved in working with patients to develop and execute care plans, provide patient education, and work collaboratively with interdisciplinary healthcare team members to optimize patient care and experience.

Responsibilities

Patient Population - (Clinical Only):

• Engages in population appropriate communication.
• Has knowledge of growth and development milestones and tasks.
• Gives clear instructions to patients/family regarding treatment.
• Involves family/guardian in the assessment, initial treatment and continuing care of the patient.
• Identifies any physical limitations of the patient and deploys intervention when necessary.
• Recognizes and responds appropriately to patients/families with behavioral health problems.
• Interprets population related data and plans care appropriately.
• Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms. Performs treatments, administers medication or operates equipment safely.
• Recognizes and responds to signs/symptoms of abuse or neglect.

Patient Assessment & Interventions:

• Acts as an expert clinician and role model in providing quality patient care to patients and their families within his/her specialty area.
• Utilizes the nursing process for direct patient care and assists the staff with assessment, planning, implementation, and evaluation of patient care needs.
• Conduct thorough assessments of patients' health status during clinic visits. Reassess and evaluate patient as needed throughout their visit.
• Document nursing history and assessment for assigned patients, initiating referrals based on patient needs.
• Collects basic level and advanced patient data. Monitors for trends that could impact patient health.
• Maintain awareness of comfort and safety needs of patients during their ambulatory appointment starting from the time they arrive to their departure. Assess patient environmental safety continuously.
• Respond to life-saving techniques based on nursing standards, policies, procedures, and protocol.
• Provide accurate hand-off report when patients are moved between ambulatory areas and/or between ambulatory and inpatient areas.
• Recognizes and reports changes in patient conditions and abnormal labs or results.
• Perform POC testing assessments as needed to support the patient's clinical well-being and also patient experience.
• Initiate and implement individualized patient care plans in collaboration with other healthcare providers based on clinical assessments, disease process, and patient's identified psychosocial needs.
• Collaboratively develops and utilizes patient care pathways that ensure consistent quality of care for patients.
• Demonstrates competency in administering medications, perform wound care, and provide other direct nursing interventions as needed.
• Completes nurse visits and documents timely and accurately.
• Assist with minor procedures and diagnostic tests, ensuring patient comfort and safety.
• Monitor patients for changes in condition, report findings to the healthcare team, and adjust care plans accordingly.
• Recruit patients for studies
• Assists and collaborates with staff nurses in quality assurance.
• Meet new patients to introduce self and explain role.
• Demonstrates ability to establish priorities of care based on individual patient assessments and the needs of the patients assigned.
• Demonstrates critical thinking and accountability in evaluating and implementing physician orders.
• Ensures timely nursing documented with exceptional accuracy according to hospital policy and procedures. Real time nursing documentation.
• Maintain positive, professional, and cooperative demeanor throughout all interactions with patients, staff, physicians, and members of management. Maintain a calm demeanor during emergent or challenging behavioral situations with patients.

Patient Education:

• Meets with patients and families to identify educational needs related to health promotion, maintenance, alterations in health status, disease processes, diagnostic testing, and interdisciplinary care within specialty area.
• Educate patients and their families about health conditions, treatment plans, medications, and self-care techniques.
• Reassess for understanding and re-educate as needed.
• Apply current nursing literature in teaching techniques and guiding standards of care in patient and family education.
• Serve as a expert patient educator for disease-based and clinic-based care teams.
• Documents patient/family/designee teaching and response appropriately.

Facilitation of Care:

• Facilitate seamless transitions of care by coordinating referrals, scheduling follow-up appointments, and ensuring timely access to services throughout continuity of care.
• Communicate effectively with patients regarding test results, treatment plans, and follow-up care.
• Address patient concerns and provide support and guidance throughout their treatment journey.
• Anticipate changing needs of patients and families based on care plan and act proactively to reduce delays in care, reduce financial toxicity, and increasing patient satisfaction.
• Participate in interdisciplinary team meetings to discuss patient care.
• Collaborate with social workers, dietitians, and other healthcare professionals to address the comprehensive needs of patients.
• Liaison to other departments and organizer for interdepartmental projects
• Participates in transitions of care planning.
• Documents plan of care reflective of collaborative practice with other health care team members.
• Support prior authorization for medication and diagnostic tests

Leadership & Professional Development:

• Serves on nursing and hospital-wide and unit-based committees that influence the delivery of patient care (example: PPO, Documentation)
• Assists with developing and revising policies and procedures for nursing practice.
• Assist with implementing evidence-based practice in the unit.
• Works collaboratively on performance improvement system wide.
• Demonstrates the nurse's role as a member of the healthcare team and promotes accountability, responsibility, and commitment regarding patient care standards.
• Serves as a resource within his/her own specialty for all members of the healthcare team.
• Orientation and other education programs as assigned.
• Serve as a preceptor and/or mentor for nursing students, clinical interns, and other healthcare professionals as needed and identifies opportunities for observation or clinical experiences.
• Remains current in research to area of clinical nursing practices
• Participates and contributes to staff meetings

Compliance & Safety:

• Maintains confidentiality of information
• Sustain an understanding of regulatory requirements and accreditation standards.
• Monitor safety and departmental policies and procedures.
• Work with department managers, nurses and nursing leadership and multidisciplinary representatives to identify and share safety best practices.
• Demonstrate an understanding of legal and regulatory issues (HIPAA, EMTALA, regulatory agencies, UC, legal P&P) impacting the care delivery and reimbursement process.
• Utilizing MIDAS effectively to report safety concerns. Able to escalate appropriately.

Other duties as assigned

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