What are the responsibilities and job description for the Registered Nurse- Care Coordinator position at Central Ohio Primary Care - Employees?
Job Description
Job Description
Central Ohio Primary Care is seeking at Care Coordinator RN to join it's Case Management team. The Care Coordinator's primary role of will be to evaluate a patient’s eligibility for hospice services and coordinate admissions to hospice programs. They manage the care for high risk, chronically and acutely ill patients by collaborating with the Care Coordination team to monitor care and treatment of patients. This position includes coordinating, facilitating, monitoring, and evaluating interventions to achieve desired outcomes. Responsibilities include coordinating with Physicians and functioning as part of an interdisciplinary team to guide high risk patients across care delivery sites, including inpatient, ambulatory, and post-acute care settings. The Care Coordinator, RN ensures continuity of care through defined, evidence-based methods, including, but not limited to, medication reconciliation, self-management plan, engagement of family and caregiver, health education and referrals. This position collaborates with other care team members to address gaps in care. This position promotes improved clinical outcomes and patient satisfaction, as well as demonstrates efficient use of resources. This is a full-time position working first shift hours Monday- Friday.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES :
- Participate in care of high risk, chronically or acutely ill patients.
- Perform complete assessment of patient's current health status, including barriers to achieving optimal health, and available resources. Identify potential gaps in care based on the assessment.
- Determine patient's eligibility for hospice services and coordinate admissions into hospice programs.
- Participate in the development and creation of an initial plan of care and self-management that highlight potential opportunities for improving clinical outcomes and / or utilization patterns. Collaborate with care team, patients, and caregivers to achieve plan of care outcomes and improve patient outcomes.
- Facilitate and monitor the developed plan of care for patients. Work with Care Coordination team to manage caseloads.
- Coordinate patient / family / caregiver participation in plan of care and self-management. Coordinate patient education to achieve plan of care using evidence-based methods.
- Perform Face-to-Face visits as necessary including home, office and skilled rehab facility settings . Evaluate possible barriers to attainment of self-management goals and develop strategies to overcome.
- Provide ongoing feedback to patient primary care team through regular communication.
- Work in collaboration with inpatient and ambulatory healthcare staff, as well as community resources as necessary to facilitate continuity of care.
- Facilitate referrals to other disciplines and internal health and community-based programs as appropriate to improve patient outcome.
- Communicate with patients via phone calls or during scheduled home visits in a timely manner. Conduct end-of-life discussions with patient / family, as needed.
- Document in the medical record as indicated and designated case management tool accurately reflecting collaborative care planning, interventions and evaluation against defined targets and goals.
QUALIFICATIONS :
A. Experience, Education, Licensures & Certifications
B. Knowledge, Skills & Abilities
