RN - Care Coordinator

Cottage Hospital’s Rowe Health Center is looking for a RN Care Coordinator to support high-risk patients and improve their access to care. In this role, you will work closely with patients, families, and healthcare providers to ensure smooth transitions of care, reduce hospital readmissions, and promote preventive health practices. If you are ready to make a meaningful difference in the lives of patients? Apply today to join our team!  

Job Summary:

The Care Coordinator works in collaboration and in continuous partnership with chronically ill, “high-risk” patients, and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in team approach to promote timely access to appropriate care. Increase utilization of preventative care; reduce emergency room utilization and hospital readmissions. Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider and family/caregiver(s).

Key Responsibilities:

• Mobilizing community resources and navigating patients through the healthcare continuum.
• Coordinates continuity of patient care with external healthcare organizations and facilities.
• Coordinates continuity of patient care with patients and families following hospital admission, discharge
  and ER visits.
• Conducts comprehensive, preventive screenings, including Medicare Annual Wellness Visits,
  Transitional Care Management, Chronic Care Management and Advanced Life Planning.
• Supports patient self-management of disease and behavior modification interventions.
• Manage high risk patient care, including management of patients with multiple co-morbidities or high
  risk for readmission to a hospital setting.
• Promotes clear communication amongst care team and treating clinicians by ensuring awareness
  regarding patient care plans.
• Performs other duties as requested or assigned.