RN Care Coordinator

Career Opportunities with Community Health Centers of the Central Coast

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Wage range that the company expects to pay: $3,076.92 - $3,392.31

SUMMARY

Under the direction of the Associate Director of Nursing, the RN Care Coordinator ensures care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient, and readmission visits. The RN Care Coordinator ensures utilization of team-based, holistic, patient-centered, evidence based approach to identify patient-centered goals and develop outcomes to improve the health status of patients served by Community Health Centers of the Central Coast. The RN Care Coordinator serves as a clinical liaison, facilitator, advocate, and collaborator in a multidisciplinary care team across the continuum of care to ensure complex disease management interventions to high risk and post discharged patients are acted upon. The RN Care Coordinator is dedicated to providing support to staff in the field and is responsible for supervising Hospital Discharge and ER Follow-Up Coordinator and Patient Navigators.

It is the primary purpose of CHCCC to provide the highest quality of total care possible to the patient population it serves. Such a level of quality depends ultimately on the staff's desire and ability to work together, individually, and as a team. The employee is expected to be professional, punctual, maintain regular attendance, cooperative, organized, and enthusiastic at all times.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Additional duties may be assigned with or without prior notice.

Conduct intake assessment, needs assessment, treatment planning, and reassessment services.

Provide day-to day support, supervision, and performance reviews for Hospital Discharge and ER Follow-Up Coordinator and Patient Navigators.

Reviews patient cases with Hospital Discharge and ER Follow-Up Coordinator and Patient Navigator and provides advice, direction, and support as needed.

Organizes or leads Hospital Discharge and ER Follow-Up Coordinator and Patient Navigator training sessions.

Provides clinical supervision to Hospital Discharge and ER Follow-Up Coordinators and Patient Navigators.

May meet with client along with Patient Navigator after primary care physician appointments to review and update care plan.

Screen clients for eligibility for direct and support services and refer clients to needed services, such as mental health, housing, crisis, and employment assistance.

Facilitate Care Team meetings with Hospital Discharge and ER Follow-Up Coordinators, Patient Navigators and health care providers to discuss client Care Plan and share information regarding referral sources.

Document client services in medical records.

Establish and retain client referral systems from care coordination systems.

Maintain documentation of all client encounters and complete reporting requirements according to organization standards.

Track client information, schedules, files, and forms in a confidential manner.

Initiate outreach and missed appointment procedures, as per CHCCC policy.

Monitors medication management as directed by clinician and within scope of practice.

Attend and represent the organization at professional conferences, in-service trainings, and meetings at the request of or with the approval of supervisor

Conduct quality assurance and monitoring activities for service delivery and documentation

Oversee the development of Coordination of Care as identified by regulatory and accrediting agencies.

Ensure compliance with administrative, legal and regulatory requirements of Health Plan contracts and Government and Accrediting agencies.

Patient safety: Accountable to promote an organizational culture of safety and ensure appropriate patient safety standards and guidelines are followed consistently in the delivery of health care to patients, including but not limited to Healthcare Effectiveness Data and Information Set (HEDIS), The Joint Commission (TJC), National Committee of Quality Assurance (NCQA), Patient Centered Medical Home (PCMH), and Uniform Data System (UDS).

Manage and resolve human resources related situations, employee and department safety and risk management issues; advises on appropriate corrective action and development opportunities.

Ensures the performance and productivity of all Care Coordination team members are evaluated on a regular basis throughout the year and annually.

Ensure that care coordination related to risk management, reimbursement, financial management and other administrative functions are incorporated into operational systems.

Monitor health outcomes related to coordination of care.

Maintains high quality of care by Care Coordination staff through continuous improvement of standards and protocols.

Collaborates with Human Resources to select, orient and train staff, and ensures all staff members are trained in care coordination functions based on job descriptions.

Stays current with state, federal and payer regulations/requirements and updates professional standards for nursing related to care coordination.

Collaborate with other services in developing and implementing innovative models and best practices, emphasizing service improvement and cost reduction.

Supports services that achieve a high level of customer service satisfaction with emphasis on service and innovation.

Participates in patient population management as it relates to clinical services while taking into