RN Inpatient Care Coordinator - Summit Medical Group

Summit Medical Group is recruiting for a RN Inpatient Care Coordinator position. This is a full time opportunity. This position provides transition of care services that

are designed to ensure health care continuity for Summit Medical Group (SMG) patients.

Examples of Duties (List does not include all duties assigned)

• Provide transition of care services post inpatient hospitalization or emergency room visit.
• Complete follow up calls as needed for a minimum of 30 days after inpatient hospitalization.
• Initiate and maintain communication with multi-disciplinary healthcare team to develop, implement, and evaluate a transition plan of care for SMG patients.
• Assess complexity of care needs and potential/actual issues.
• Arrange post-discharge referrals to Care Management RN or SW to assist with chronic disease management or community resource need.
• Facilitate closing gaps in care.
• Assist patient in scheduling hospital follow up, emergency room and other medical appointments.
• Conduct medication reconciliation within 30 days of inpatient hospital discharge.
• Submit CPT code 1111F for Medicare Advantage patients within 30 days of hospital discharge.
• Educate patients on appropriate use of the emergency room, primary care, specialist, and urgent care.
• Facilitate patient understanding of the physician's treatment plan, including but not limited to medication adherence, preventive care, and self-management skills.
• Facilitate the sharing of medical information across the continuum of care.
• Document transition of care encounters and other clinical correspondence in electronic medical record (EMR).
• Act as an advocate for an individuals health care needs by identifying and communicating potential needs to the patient's provider.
• Collaborate with skilled nursing facilities to identify inpatient or discharge status as well as confirm SMG patient status.
• Collaborate with home health agencies to ensure ongoing care, support, and education.
• Maintain security and privacy of patients by keeping patient care information confidential.
• Participate in required training and attend team, departmental, and organizational meetings.
• Monitor and improve quality of services provided to patients/caregivers through ongoing participation in team and departmental quality improvement activities.
• Update job knowledge by participating in educational opportunities that support the advancement of Care Coordination including care transitions.
• Participate in the orientation and training of new staff as needed.
• RN Inpatient Care Coordinator job description is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities that are required of the employee for this position. To deliver exceptional customer experience and consistently meet the needs of SMG, additional duties responsibilities may change at any time.
• Maintains strictest confidentiality both internally and externally
• Adheres to expectations of the established corporate compliance plan.
• Actively participates in site-level Quality Improvement Activities. Each employee will contribute to the continual evaluation site performance as well as the implementation and measurement of improvement activities that increase the quality of care provided to patients.
• Performs related work as assigned.

Education

Registered Nurse - Graduated from a board approved nursing program and maintains and unencumbered license to practice in the state where employed.

Experience

Minimum 2 years of experience in clinical experience with preference for those that have worked in a Primary Care setting.

Certification/License

Valid State of Tennessee Registered Nurse License