Position Summary:
The Scope of practice for a registered nurse according to CT State Statute Sec. 20-87a, (a) The practice of nursing by a registered nurse is defined as the process of diagnosing human responses to actual or potential health problems, providing supportive and restorative care, health counseling and teaching, case finding and referral, collaborating in the implementation of the total health care regimen, and executing the medical regimen under the direction of a licensed physician, dentist, or advanced practice registered nurse. A registered nurse may also execute orders issued by licensed physician assistants, podiatrists, and optometrists, provided such orders do not exceed the nurse's or the ordering practitioner's scope of practice. A registered nurse may execute dietary orders written in a patient's chart by a certified dietitian-nutritionist.
The Care Coordination RN assists patients to navigate through the healthcare system by acting as a patient liaison. Facilitates patient education and access to healthcare and community resources. Coordinates continuity of patient care with external healthcare organizations and facilities, including the following transitions of care: hospital admission, discharge, and referrals from the family/primary care provider to specialty care providers. Understands the Accountable Care Organization (ACO) structure and independently manages patient panels and navigate payor systems. Provides clinical care within the scope of the RN license. Administers medications and immunizations as necessary. Works collaboratively with physicians, APRN’s, LPNs, Medical Assistants, and other staff.
Essential Functions & Responsibilities:
The Care Coordination RN will work with the patient care team to carry out activities that will achieve the desired outcomes of chronic care management for the identified high-risk patient population as well as the Medicare and Managed Medicare population, serving to increase access to care, decrease costs to the health system, and improve patient outcomes. The RN will:
Serve as the point-of-contact, advocate, and informational resource for assigned patients, care team, family/caregiver(s), payers, and community resources.
Develop a cohesive and strong team-oriented relationship with physicians, nurses, and other healthcare professionals; evaluate and report on patient health outcomes and work in partnership with interdisciplinary healthcare team to facilitate the best for patient care.
Work with patients to plan and monitor care:
Outreach and conduct qualifying Annual Wellness Visits (AWVs) when applicable.
Develop a patient specific Care Plan that provides goals and interventions to implement, monitor, and support the needs of the patient as defined by the PCP
Document within the electronic health record and various external platforms to review data, SDOH and close gaps in care to improve patient outcomes and maximize reimbursement.
Run reports and analyze data regarding metrics and collaborate with providers to develop plans to improve outcomes on these metrics.
Meet quarterly and as needed with payor representatives to discuss enrolled patients.
Assist patients to make informed decisions about their care by acting as their advocate regarding their clinical status and treatment options.
Accountable for remaining current with knowledge of care management, availability of community resources and quality improvement methodologies.
Responsible for appropriately identifying patients for care management utilizing multiple sources including physician referrals, referrals from transitions of care, health plans as well as complex lists of patients from the ACO.
Provide feedback for the improvement of the Care Coordination Program
Promote quality and cost-effective interventions and outcomes for patients in collaboration with the primary care providers and/or specialists.
Manage transitions of care for patients discharged from the hospital, behavioral health facility/program, emergency room, or from a skilled nursing facility. Responsible for reviewing the discharge summaries, follow up on testing that is pending, and ensure ordered services are in place. Outreach to patients to perform a medication review, ensure patients understanding of discharge instructions and assess for further care management needs.
Provide disease management/complex care management to patients face to face or telephonically as well as utilizing technology that becomes available.
Review care management program metrics including emergency room utilization, and hospital admission/readmission data on a regular basis.
Develop processes to collect data to identify trends in utilization of health care resources.
Assume accountability for own professional practice and for aspects of patient care delegated to others.
Practice within the ethical and legal parameters of nursing practice
Lead and/or participate in interdisciplinary team meetings.
Additional General Requirements: Professional positive attitude, understanding of customer service principles, trustworthiness, and excellent interpersonal skills.
Job Qualifications/Requirements:
Education:
Graduate of an accredited Nursing Program, 4-year Baccalaureate Degree in nursing preferred.
CCM training; performing an AWV, documentation and coding, closing gaps in care, Care Screen, enrolling patients into CCM, conducting CCM visits. Knowledge of funding resources and clinical standards and outcomes.
Possess and demonstrate critical thinking skills and clinical problem-solving techniques.