Care Coordinator-Renal Transition Coordinator

We are searching for a Care Coordinator - someone utilizing a collaborative approach to assess, plan, implement, monitor and evaluate the options and services required to meet an individual's health needs. Provides comprehensive on-going case management services to patients by coordinating and managing care of patients to meet multiple service needs across the continuum of care. Someone to ensure optimal patient outcomes that address quality, service, customer satisfaction and cost effectiveness. This care coordinator will partner with the physician to establish care and allocate resources associated with the patient's risk assessment and assist the patient/patient's family in coping with illness by optimizing the patient's/family's self-care abilities and supporting their consumer rights.

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"As part of our commitment to maintaining a safe and healthy workplace, all successful candidates will be required to undergo respiratory fit testing in compliance with occupational health and safety standards. "

• Assesses, develops, implements and monitors a comprehensive plan of care through an interdisciplinary team process in conjunction with the patient/family in internal and external settings

• Reviews clinical documentation and collaborates with medical and nursing staff to ensure smooth facilitation of level of care and patient placement

• Identifies actual and potential problems and discusses with the multi-disciplinary team to facilitate interventions to mitigate barriers to successfully implementing plan of care

• Serves as content expert related to level of care and maintains open communication with the care team to support appropriate utilization of resources

• Appropriately screens patient for level of care and ensures clinical information in the medical record accurately reflects the level of care requested

• Coordinates timely transition of information to unit Care Coordinator to support effective revenue cycle process

• Completes visits with patient across the continuum of care as indicated

• Participates in the orientation and training of new department members

• Identifies and monitors quality improvement opportunities along the continuum of care

• Identifies and reports quality of care, safety and quality of services issues and refer to appropriate Quality Management staff.

• Solves problems, identifies appropriate resources, adapt to ongoing change, and handle conflict management with a professional and supportive attitude

• Uses positive and effective interpersonal skills when dealing with patients/families, visitors, peers, and other health care team members

• Bachelor's degree in nursing or an associate's in nursing with enrollment in a BSN program

• Current RN Licensure by the Texas Board of Nurses or Nursing licensure compact

• BLS from AHA

• 3yrs of nursing experience in an acute care setting

• experience in community health, complex pediatric patient care, home care, case management, managed care, or utilization review highly preferred