Registered Nurse Care Coordinator
Summary of Position:
This is a safety sensitive position The Registered Nurse Care Coordinator (RNCC) works collaboratively with a multidisciplinary team to provide care coordination for patients who are experiencing or at risk for homelessness. The RNCC is a critical member of the patient care team who is responsible for developing and implementing a care coordination program throughout CTC's continuum of care including outpatient family health centers, Respite Centers, and mobile unit-based outreach programs. The RNCC will focus on patient-centered health optimization and disease management for high risk and/or complex patients through risk stratification and evidence-based clinical guidelines.Essential duties:
Duties include, but are not limited to:
o Identifies patients experiencing or at risk for homelessness who meet criteria for care coordination (focusing on those who have multiple co-morbidities and/or are high utilizers of services) through risk stratification and provider referral. o Provides care management, care coordination, and health coaching for the purpose of empowering patients to improve health. o Develop culturally appropriate, comprehensive individualized patient-centered plans of care and implement targeted interventions based on risk stratification and evidence-based clinical guidelines. o Conducts interviews to assist patients in identifying barriers to care and social determinants of health and appropriately refers patients to community resources as needed. o Maintains an updated list of community resources. o Continually monitors patient response to plan of care and revisions as needed. o Provides self-management support with a focus on empowering the patient to build capacity for self-care, providing resources and education as necessary. o Coordinates patient-centered care through ongoing collaboration with provider, patient, community, and other members of the healthcare team. Fosters a team approach and includes patients as active members of theteam. o Performs medication management with ongoing medication regimens and develops a patient directed self-management strategy for active participation. o Assists with pre-visit planning for patients prior to appointments to close gaps in care, plan for preventative care, and addresses any outstanding referrals. o Maintains required documentation within the Electronic Health Record of all patient and healthcare team interactions, including documenting preventive care and services performed elsewhere. o Conducts follow-up phone calls to patients to ensure they are meeting their goals and updates the status ofmanaging their health issues. Oversees efforts and staff (i.e. medical assistants, RNs, or other staff) responsible for coordination of care efforts. o Uses data systems to monitor gaps in care. o Recognizes data hygiene inconsistencies to improve population health reporting efforts. o Monitors EMR tasks and messages to assure timely management and response to patient and provider concerns and requests. o Has an understanding and general knowledge of behavioral health diagnoses. Understands and utilizes the basics of motivational interviewing. o Contributes to the integrated care team's activities around process improvement, workflow design and training. o Participates in organizational Quality Assurance/Quality Improvement and Risk Management programs.
Qualifications:
Basic Knowledge and Skills:
o Graduate of an accredited school of nursing with a current Arizona RN license in good standing. o Certified in IV therapy, phlebotomy. o Minimum three (3) years' experience in outpatient clinic, public health care, urgent care or emergency dept. o Competent in basic nursing knowledge of illnesses and treatments. o Understanding of substance and mental health issues. o Computer proficiency inclusive of ability to access, enter, and interpret computerized data/information is required including use of electronic health records. o Excellent communication skills. o Care management experience highly preferred. o Experience in continuous quality improvement. o Experience in a community health center preferred. o Bilingual (English/Spanish) preferred. o Basic Life Support certification required (BLS). o Able to adapt to rapid, unpredictable workflow. o Able to focus on work at hand with attention to detail. o Ability to work with difficult patients and those with mental illness. o Must be at least 21 years of age.Physical and Mental Requirements:
o Position requires extended periods of sitting and standing. o Position requires extended periods of sitting and standing. o Position requires regular bending and reaching, including transfer of patients. o I have reviewed the physical requirements form. Recommended Skills Adaptability Attention To Detail Basic Life Support Behavioral Medicine Business Process Improvement Care Coordination Apply to this job. Think you're the perfect candidate? Apply on company site $(document).ready( function() $(#ads-desktop-placeholder).html(
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n Estimated Salary: $20 to $28 per hour based on qualifications.
This is a safety sensitive position The Registered Nurse Care Coordinator (RNCC) works collaboratively with a multidisciplinary team to provide care coordination for patients who are experiencing or at risk for homelessness. The RNCC is a critical member of the patient care team who is responsible for developing and implementing a care coordination program throughout CTC's continuum of care including outpatient family health centers, Respite Centers, and mobile unit-based outreach programs. The RNCC will focus on patient-centered health optimization and disease management for high risk and/or complex patients through risk stratification and evidence-based clinical guidelines.Essential duties:
Duties include, but are not limited to:
o Identifies patients experiencing or at risk for homelessness who meet criteria for care coordination (focusing on those who have multiple co-morbidities and/or are high utilizers of services) through risk stratification and provider referral. o Provides care management, care coordination, and health coaching for the purpose of empowering patients to improve health. o Develop culturally appropriate, comprehensive individualized patient-centered plans of care and implement targeted interventions based on risk stratification and evidence-based clinical guidelines. o Conducts interviews to assist patients in identifying barriers to care and social determinants of health and appropriately refers patients to community resources as needed. o Maintains an updated list of community resources. o Continually monitors patient response to plan of care and revisions as needed. o Provides self-management support with a focus on empowering the patient to build capacity for self-care, providing resources and education as necessary. o Coordinates patient-centered care through ongoing collaboration with provider, patient, community, and other members of the healthcare team. Fosters a team approach and includes patients as active members of theteam. o Performs medication management with ongoing medication regimens and develops a patient directed self-management strategy for active participation. o Assists with pre-visit planning for patients prior to appointments to close gaps in care, plan for preventative care, and addresses any outstanding referrals. o Maintains required documentation within the Electronic Health Record of all patient and healthcare team interactions, including documenting preventive care and services performed elsewhere. o Conducts follow-up phone calls to patients to ensure they are meeting their goals and updates the status ofmanaging their health issues. Oversees efforts and staff (i.e. medical assistants, RNs, or other staff) responsible for coordination of care efforts. o Uses data systems to monitor gaps in care. o Recognizes data hygiene inconsistencies to improve population health reporting efforts. o Monitors EMR tasks and messages to assure timely management and response to patient and provider concerns and requests. o Has an understanding and general knowledge of behavioral health diagnoses. Understands and utilizes the basics of motivational interviewing. o Contributes to the integrated care team's activities around process improvement, workflow design and training. o Participates in organizational Quality Assurance/Quality Improvement and Risk Management programs.
Qualifications:
Basic Knowledge and Skills:
o Graduate of an accredited school of nursing with a current Arizona RN license in good standing. o Certified in IV therapy, phlebotomy. o Minimum three (3) years' experience in outpatient clinic, public health care, urgent care or emergency dept. o Competent in basic nursing knowledge of illnesses and treatments. o Understanding of substance and mental health issues. o Computer proficiency inclusive of ability to access, enter, and interpret computerized data/information is required including use of electronic health records. o Excellent communication skills. o Care management experience highly preferred. o Experience in continuous quality improvement. o Experience in a community health center preferred. o Bilingual (English/Spanish) preferred. o Basic Life Support certification required (BLS). o Able to adapt to rapid, unpredictable workflow. o Able to focus on work at hand with attention to detail. o Ability to work with difficult patients and those with mental illness. o Must be at least 21 years of age.Physical and Mental Requirements:
o Position requires extended periods of sitting and standing. o Position requires extended periods of sitting and standing. o Position requires regular bending and reaching, including transfer of patients. o I have reviewed the physical requirements form. Recommended Skills Adaptability Attention To Detail Basic Life Support Behavioral Medicine Business Process Improvement Care Coordination Apply to this job. Think you're the perfect candidate? Apply on company site $(document).ready( function() $(#ads-desktop-placeholder).html(
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n Estimated Salary: $20 to $28 per hour based on qualifications.
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