Registered Nurse- Care Coordinator

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.  This position will cover Northwest Columbus region.

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 

• Required: 5 or more years of clinical and case management experience in a hospital, home health/hospice, or managed care setting
• Required: Active Ohio RN license 
• Preferred: CCM certification; Bachelor’s degree in nursing

B. Knowledge, Skills & Abilities

• Must be able to perform any clinical or clerical duty as assigned skillfully
• Must demonstrate the ability to handle stressful situations appropriately
• Must be able to work flexible hours as needed
• Must demonstrate ability to manage case load and document progress in a timely way as outlined by the care program assigned to each patient
• Must maintain patient confidentiality
• Must demonstrate a proficient driving record and up to date auto insurance as travel to visit patients is necessary
• Knowledge of chronic and acute disease states in adults
• Knowledge of common medications used in a primary care setting including indications, dosages and side effects 
• Knowledge of trends in healthcare, managed care, Medicaid, case management, medical management and quality improvement
• Proficient in computer software and usage including but not limited to Microsoft Outlook and Microsoft Excel
• Strong analytical, organizational, and time management skills
• Ability to work independently and within a team environment with minimum supervision
• Ability to demonstrate work toward the progress of patient-centered goals
• Ability to develop and maintain rapport among health care professionals within individual COPC practices
• Ability to adapt to changing environment
• Ability to administer IM medication
• Ability to perform straight or indwelling catheter procedures, blood draw, nebulizer treatment, etc. as necessary
• Provide same day or next day HV’s for assessment as needed (i.e., lab specimen collection, education, and treatment plans adjustments with collaboration providers.
• Excellent written and verbal communication skills; ability to communicate effectively in stressful situations
• Self-disciplined, energetic, passionate, and innovative
• Decision making/problem solving skills
• Critical and ‘systems' thinker
• Strong attention to detail
• Training/teaching skills
• Demonstrate awareness and ability to work alongside diverse cultures and patient populations
• Commitment to customer service