Population Health RN Care Coordinator

JOB SUMMARY: The Nurse Care Coordinator delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures. Drawing on best practices in motivational interviewing and care management, the Nurse Care Coordinator collaborates with clients and multi-disciplinary teams to develop and implement flexible, patient-centered, and cost-effective strategies that support clients to achieve health-related goals. The Nurse Care Coordinator will collect and analyze patient-level data, assist with development and maintenance of care plans, and evaluate outcomes of interventions. The Nurse Care Coordinator also serves as a role model and mentor to CBHC staff on best practices in care coordination, motivational interviewing and addressing social determinants of health. Assures compliance with regulatory body standards (including Joint Commission, HRSA, PCMH, and grant funding sources). This is a hybrid position, and the staff member is expected to be licensed and based in Maryland.

MAJOR DUTIES AND RESPONSIBILITIES:

Analytical and Critical Thinking \u00b7

Work to develop systems and processes to engage patients in self-management and care navigation. \u00b7 Ensure that appropriate community resources, home care and ancillary services are in place and being delivered. \u00b7 Identify high and rising-risk, high-need, and potentially high-cost patients within the assigned panel of Chase Brexton Health Care patients \u00b7 Identify patients at risk for poor outcomes and those who may require more intensive services; provide additional outreach and frequent follow up (by phone and in-person) to this population. \u00b7 Provide complex case management, including chronic disease case management, care coordination, transition care management, high risk clinical tracking, and complex medication management to appropriate patients. \u00b7 Access appropriate resources inside and outside the organization to meet the needs of the patient. \u00b7 Provide referrals to appropriate community resources; facilitate access and communication when multiple services are involved; monitor activities to ensure that services are actually being delivered and meet the needs of the patient, coordinate services to avoid duplication. Teamwork \u00b7 Role model and mentor others, including RN Care Managers, to assess and address the physical, functional, social, psychological, environmental, learning and financial needs of patients.

Communication

• Deliver, and assist others to also provide, appropriate interventions which demonstrate knowledge of, and sensitivity toward, cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Utilize interpreter services per policy. \u00b7 Facilitate disease prevention and health promotion with nursing staff, patients and families. Patient Focus \u00b7 Provide education, information, and support related to care goals of patients. \u00b7 Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan. Checking, Examining, and Recording \u00b7 Maintain accurate patient records and patient confidentiality. Willingness to Learn \u00b7 Engage in professional development activities to keep abreast of care management practices and patient engagement strategies. \u00b7 Attend training sessions and staff meetings as assigned.

SKILLS AND ABILITIES: \u00b7

Able to prioritize competing responsibilities and manage complex caseloads. \u00b7 Motivational interviewing skills. \u00b7 Supportive coaching and mentorship to colleagues at clinic sites, including RN Care Managers, around care coordination and addressing social determinants of health. \u00b7 Experience with documentation in an Electronic Medical Record \u00b7 Ability to work with computers in word processing, and database applications preferred. \u00b7 CPR certified by scheduled start date. \u00b7 Must be flexible and adapt to a changing environment.

EDUCATION AND/OR EXPERIENCE: \u00b7

Graduate from an Accredited School of Nursing; Current Maryland Nursing License \u00b7 At least five years of related nursing experience serving vulnerable clients in a community-based, home-based, or ambulatory care setting. \u00b7 Chronic disease management experience \u00b7 Encouraged to maintain membership in professional organizations such as the AAACN, ANAC, etc. \u00b7

Preferred: Case Management Certification

WORKING CONDITIONS/PHYSICAL DEMANDS: \u00b7 Work is typically performed in an office environment. Depending on client/population needs, may also include clinical and community and/or home-based activities, as appropriate to program. The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

My signature below indicates that I have reviewed this job description. I understand the specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

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