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Healthcare Care Coordinator

2 semanas atrás

São Francisco de Assis, Brasil beBeeCareCoordinator Tempo inteiro R$35.967 - R$53.932
Job Summary

The RN Care Coordinator will be responsible for ensuring care coordination for a panel of patients to achieve optimal outcomes and wellness, while decreasing preventable ED, inpatient, and readmission visits.

Under the direction of the Associate Director of Nursing, the RN Care Coordinator will utilize a team-based, holistic, patient-centered approach to identify patient-centered goals and develop outcomes to improve the health status of patients served by our organization.

The RN Care Coordinator will serve as a clinical liaison, facilitator, advocate, and collaborator in a multidisciplinary care team across the continuum of care to ensure complex disease management interventions are acted upon.

The RN Care Coordinator will provide support to staff in the field and be responsible for supervising Hospital Discharge and ER Follow-Up Coordinator and Patient Navigators.

The primary purpose of our organization is to provide the highest quality of total care possible to the patient population it serves.

The employee is expected to be professional, punctual, maintain regular attendance, cooperative, organized, and enthusiastic at all times.

Essential Duties and Responsibilities:
  • 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 healthcare 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 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 healthcare to patients
  • 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 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 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 account cultural diversity and local resources
  • Participates in the team member's care coordination by providing follow-up phone calls post hospital discharge. Assists the patient with follow-up appointments within the recommended time frames and gathers data from recent hospital admissions to facilitate follow-up
  • Understands the role in self-management support and has the ability to refer to a licensed clinician when clinical judgment is in question
  • Develop communication skills with all members of the team both internal and external, by first being a patient advocate and use the available resources to facilitate care. Coordinate with the Care Team (PCP, RN, Patient Navigator, Health Educator, LCSW, other nursing staff, ie CMA/RMA, and/or Medical Director) to ensure appropriate services are arranged for the patient in order to improve health outcomes
  • Understand the role in the quality improvement process, which may include meetings, data collection, and charge auditing. Use Evidence-based practice guidelines to assist with disease management
  • Must demonstrate strong understanding of cultural competency with the target population
  • Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served (infants, pediatrics, adolescents, adults, or geriatrics)
  • Demonstrates knowledge of domestic violence, child, and dependent abuse protocols
  • Demonstrates adherence to and observes all safety policies and procedures, inclusive of infection control rules and regulations
  • Maintains and adheres to confidentiality, and privileged communications (patient, employee, and corporation)
Supervisory Responsibilities:

Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, training employees, planning, assigning and directing work, appraising performance, rewarding and disciplining employees, addressing complaints and resolving problems

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

Graduation from an accredited School of Nursing. Associate Degree in Nursing required; BSN preferred. Minimum five (5) years of nursing experience with a minimum of two (2) years in care coordination/case management experience. Knowledgeable about Federally Qualified Health Centers and Value-Based Care. Demonstrates strong interpersonal skills. Demonstrates knowledge of Nursing Practice, TJC, and other local, state, and federal agencies

Language Skills:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization