RN - Registered Nurse - Care Coordinator

Key Details 

• Department: Care Coordination
• Schedule: Monday - Friday, 8am - 4:30pm
• Hospital: Witham Health Services
• Location: Lebanon, IN

Job Summary 

The Care Coordinator coordinates team based care to provide health services to individuals, families and/or their communities through effective partnerships with patients, their caregivers and their physician. Facilitates a shared goal model within and across settings to achieve coordinated high quality care that is patient/family centered.

Minimum Qualifications/Requirements 

• Graduate from an accredited school of nursing program; BSN preferred.
• Valid license to practice Nursing in the State of Indiana.
• 3-5 years' experience in clinical or community health settings.
• Previous Care Coordination and/or Case Management experience preferred.
• Demonstrates evidence of essential leadership, communication, education, and counseling skills.
• Proficient in communication technologies (email, cell phone, etc.).
• Effective organizational skills, demonstrates ability to maintain accurate notes and records.
• Previous experience with health IT systems and data reports preferred.
• Previous experience with mobilizing community resources, navigating through the healthcare continuum and working with disparate populations preferred.
• Ability to speak Spanish as a second language preferred.

Competencies/Essential Functions 

• Core values consistent with a patient/family centered approach to care.
• Demonstrates professional, appropriate, effective written, verbal and nonverbal communication skills.
• Demonstrates a positive attitude and respectful, professional customer service.
• Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
• Proactively acts as patient advocate, responding with empathy and respect to resolve patient/family concerns. Recognizes opportunities for improvement to meeting patient concerns.
• Demonstrates continual learning skills, effects changes in approach to care based on established evidence based practice.
• Demonstrates professional practice behavior, provides mentoring/coaching of other population health/care coordination team members.
• Cultivates effective partnerships and collaboration with physician providers.
• Demonstrates understanding of use of I.T. resources and patient databases to promote successful/appropriate provider encounters.
• Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.

Duties and Responsibilities 

• Provide a coordinated strategic approach to detect early and manage effectively the patient with chronic disease. Establish an effective internal tracking system for identified patients.
• Coach patients/families toward successful self-management of their chronic disease.
• Utilizing tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
  • Assess patient and family's unmet health and social needs.
  • Provide effective communications to improve health literacy
  • Develop a care plan based on mutual goals with the patient, family, and providers (emergency plan, medical summary, and ongoing action plan, as appropriate).
  • Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely way, and facilitate changes as needed.
  • Create ongoing processes for patients and families to determine and request the level of care coordination support they desire at any given point in time.
• Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
• Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g. Diabetes Educator).
• Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
• Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
• Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
• Develop systems to prevent errors (e.g. effective medication reconciliation and shared medical records)
• Facilitate and attend meetings between patient, family, care team, payers, and community resources, as needed.
• Attend all Care Coordination related training and meeting activities.
• Provide feedback for the improvement of the Care Coordination Program.
• All other duties as assigned.