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GWU Medical Faculty AssociatesWashington, DCFull Time
The RN Care Coordinator provides patient-centered care management services for patients with multiple chronic conditions, in conjunction with the Primary Care Provider (Physician or Advanced Practitioner) and the Community Health Worker. The RN Care Coordinator will provide care for patients in a Medicare Accountable Care Organization (ACO) by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans within the scope of nursing practice and in accordance with the prescribed plan of care. This individual performs duties telephonically or in the clinic to engage patients with their primary care team and works with the Community Health Worker to provide coordinated care.
Essential Duties and Responsibilities include the following. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Other duties may be assigned.
This position reports to the Quality and Safety Nurse Manager at the Medical Faculty Associates (MFA). Primary duties may include, but are not limited to:
The primary responsibilities are to:
Work with patients at high risk for hospitalization and emergency department visits to better manage chronic conditions and achieve the patient’s and care team’s health goals.
Complete hospital discharge follow-up calls for all ACO patients and document appropriately.
To meet the primary responsibilities, the RN Care Coordinator is expected to:
Assess patients at high risk for hospitalization and emergency department visits and identify individual needs to better manage chronic conditions and achieve the patient’s and care team’s health goals.
Demonstrate knowledge of clinical guidelines for the treatment of chronic health conditions.
Develop a specific care management plan to address the objectives identified during assessment within the context of the patient’s functional status, health literacy, and psychosocial needs.
Apply knowledge of managed care principles in the development of the care management plan
Collaborate with the Primary Care Provider and other members of the patient’s care team to implement the care management plan.
Facilitate patient access to services including referrals to both internal and community resources, including scheduling of appointments, to meet identified needs.
Act as a resource and assist patients with coordination of care within the MFA and with external providers in a timely manner.
Complete hospital discharge follow-up calls for all ACO patients and documenting appropriately.
Current, unrestricted RN license in DC required upon hire.
Nursing specialty certification is preferred.
BS in Nursing.
3+ years of nursing experience in a clinical setting, including 2 years of nurse care management or navigation experience required.
Medicare experience preferred.
Proficiency with electronic health record usage required and proficiency with MS Word and MS Excel preferred.
Certified Nurse Practitioner
Electronic Medical Record
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