Description
Job Title: Care Coordinator- Registered Nurse
Department: Behavioral Health
Location: Massena, NY
Hours Per Week: Per Diem
Schedule: 8-hour shifts with floating expected
SUMMARY: The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach. Facilitates “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered that address. Acts as a liaison between patients and the healthcare system. Ensures that patients receive the care they need and that they understand their medical condition, medications, and other instructions. Coordination of patient-care services to help reduce costs by reducing duplication of services.
RESPONSIBILITIES:
Care Coordination
Systematically identifies individual patients and plans, manages and coordinates their care, based on condition, needs and on evidence-based guidelines based on quality goals of organizations and population needs.
Develops, formulates, implements, and revises self-management care plans with a shared-goal model, incorporating patient specific education as appropriate for high risk patients and others, as defined by the practice.
Evaluation of patient responses to interventions, identifying and developing strategies to barriers in achieving positive clinical outcomes.
Coordinates care with community and regional ancillary health services for extended needs of patients and ensures that patient specific care plans are developed and documented by the practice clinical team.
Educates patients with appropriate method suitable for individual learning abilities regarding diet, medication, or test needs, if not bringing to the attention of the physician.
Assist with data collection and generation of patient registry reports. · Attends and participates in team/educational conferences as needed.
Care Delivery
Maintains safe and effective nursing care rendered directly or indirectly, adjusting nursing care processes as necessary to ensure optimal patient care.
Triage patient phone calls.
Leads patient care team in daily and/or weekly huddle discussions to prepare for the day or week ahead.
Works closely with community resources to coordinate care needed by high risk patients, as defined by the practice.
Responsible for coordinating and leading patient support groups and/or shared medical appointments.
Quality & Regulatory
Participates in Performance Improvement/Continuous Quality Improvement activities, as assigned.
Other duties may be assigned, required, or change to meet the business needs.
REQUIRED QUALIFICATIONS:
AAS in Nursing
Valid NYS RN License
PREFERRED QUALIFICATIONS:
BS in Nursing
3-5 years’ experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.
Experience in working in partnership with the interdisciplinary healthcare team.
Excellent interpersonal skills (strong written and verbal communication skills).
Experience utilizing an Electronic Medical Record
Demonstrate ability to apply decisive, sound, objective clinical judgment for cases with varying complexity.
Experience with Patient-Centered-Medical Home desirable.
PHYSICAL REQUIREMENTS: M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.
PAY RANGE: $29.81 - $52.88
The listed base pay range is a good faith representation of current potential base pay for successful applicants. It may be modified in the future. Pay is determined by factors including experience, clinical licensure date, relevant qualifications, specialty, internal equity, location, and contracts.
