[Hiring] RN Care Coordinator @CommonSpirit Health

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 tailor custom care plans for each patient.
• Develop enhanced care plans to yield optimal outcomes for each patient.

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

• Assists in development, implementation, and revision of individual care plans.
• Monitors progress toward goals, including documentation of daily improvement in patient's condition.
• Identifies barriers and assists the patient and family/caregiver in developing appropriate care plans.
• Teaches, coaches, and educates the patient, family, and/or caregiver about their disease process.
• Documents patient, family, or caregiver's knowledge regarding medical condition(s).
• Supports the medical management plan provided by the patient's primary and specialty providers.
• Promotes patient self-management, problem-solving, and empowers patients to achieve maximum levels of wellness and independence.
• Assists patients with navigating the healthcare system to minimize fragmentation in services.
• Monitors 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.

Preferred

• 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.