RN Care Coordinator - Adult Neurology

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Job Description

Care coordination and transition management necessitates professional assessment, patient risk identification and stratification, and identification of individual patient needs and preferences that include but are not limited to the RNCC:

• Demonstrating the use of the UVA Professional Practice Model through nursing professional practice, quality achievement, lifelong learning, empowered leaders, innovation, and expert caring.
• Planning, coordinating, and prioritizing patient care activities considering patients' unique needs and desired outcomes in collaboration with the inter-professional team including consult recommendations and escalation as needed.
• Maintaining safety and continuity of care using methods such as documentation, hand-off tools/processes, etc.
• Collaborating and advising patients, families, and caregivers in their healthcare decisions, respecting their culture and values.
• Providing health education and coaching to patients tailored to issues identified within treatment and service plans through evidence-based care delivery and safety standards.
• Providing facilitative leadership that promotes health equity across the continuum and among interdisciplinary teams to improve population health, patient experience, and cost reduction.
• Demonstrating knowledge and ability to participate in and apply research and evidence-based practices for the improvement of patient care throughout the lifespan and across the continuum.
• Taking the lead in ensuring the continuity and consistency of care across the continuum to promote and facilitate pre-visit coordination, post-clinic follow-up, and handoff between services, along with monitoring and facilitating transitions of care.
• Educating patients & families with chronic illness about evidence-based standards of practice to empower patients to include self-management strategies.
• Identifying support needs and developing action plans and guidance to initiate patient-centered care planning and application of the nursing process.
• Contributing to problem-solving through communication and collaboration and evaluating outcomes of treatment options to include tracking patient progress toward care plans and goals.
• Supporting medication management
• Other duties as assigned.
• UVA Nursing Professional Practice Model
• Relationship Based Care - Self and Colleagues: reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience.
• Relationship Based Care - Patients and Families: reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience.
• Expert Caring: encompasses clinical assessment, planning, prioritizing, coordinating, and implementation of care.
• Empowered Leaders: demonstrate knowledge of and actively participate in shared governance
• Lifelong Learners: encompasses professional development through formal education, professional certification, and internal and external learning opportunities and recognizes the value of external professional organizations. Supports onboarding of new team members and precepts as applicable.
• Quality Achievement: includes adherence to clinical documentation guidelines, comprehension of outcomes data, engagement in performance improvement activities, and commitment to standard work.
• Innovation: is demonstrated by the application of technologies that support patient care, actively seeking to implement evidence-based practice and new knowledge generated by nursing research.
  
  

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