[Hiring] RN Care Coordinator @Dignity Health Medical Foundation

Role Description

As our RN Care Coordinator, you will coordinate care and collaborate with multiple disciplinary team members across the continuum of care to improve the quality of care and clinical outcomes for members with complex care needs.

• Conduct thorough assessments to determine unmet needs and develop individualized care plans.
• Evaluate and identify knowledge gaps in disease process and treatments.
• Determine appropriate resources or services required to meet an individual's health needs.
• Provide education/coaching on disease self-management for health promotion and maintenance.
• Promote quality cost-effective outcomes with the goal of improved care coordination amongst providers.
• Increase involvement of the individual family and/or caregiver in the decision-making process to reduce hospitalizations, readmissions, and ER visits.
• Conduct both telephonic case management and direct patient contact through follow-up at clinic appointments and/or home visits, as needed.
• Show compassion and use critical thinking skills to create custom care plans tailored to patient needs.
• Develop enhanced care plans, yielding optimal outcomes for each patient.
• Assist in development, implementation, and revision of individual care plans.
• Monitor progress toward goals, including documentation of daily improvement in patient's condition.
• Assist the patient and family/caregiver in developing, documenting, and implementing appropriate care plans.
• Teach, coach, and educate the patient, family, and/or caregiver about their disease process.
• Document patient, family, or caregiver's knowledge regarding medical condition(s).
• Support the medical management plan provided by the patient's primary and specialty providers.
• Promote patient self-management, problem-solving, and empower patients, families, and/or caregivers.
• Assist patients with navigating the healthcare system to minimize fragmentation in services.
• Monitor patient's compliance with scheduling and keeping PCP and specialist appointments.

Qualifications

• Two (2) years clinical experience as a RN in acute, ambulatory care, home health, skilled nursing facility, medical group, or health plan setting required.
• A Masters Degree in nursing with a concentration in Case Management can serve as a substitute for the experience requirement.
• Current CA Registered Nurse (RN) license.
• Excellent customer service and presentation skills are a must.
• Strong interpersonal and written communication skills are essential.
• Demonstrated ability to apply analytical and problem-solving skills.
• Ability to demonstrate leadership skills to delegate and provide direction/guidance to multidisciplinary teams.
• Demonstrated ability to manage multiple tasks or projects effectively.
• Ability to work independently as needed with a high degree of detail orientation.
• Ability to work efficiently in a fast-paced environment with changing priorities.
• Knowledge of regulatory and accreditation standards (URAC NCQA) and complex case management (CMSA).
• Knowledge of community resources.
• Knowledge of capitation/HMO insurance payers and government healthcare plans and audit.

Requirements

• Prior Care Coordination experience in a clinical or insurance setting is required.
• If operational conditions permit, training a candidate without the required experience may be considered.
• BSN degree or experience equivalent preferred.
• Case Management (CM) certification preferred.

Benefits

• This position is work from home for California residents.
• This position is a non-benefitted, on-call position.