RN Care Coordinator
Company: HAMILTON HEALTH CENTER INC
Posted on: May 12, 2022
All About Hamilton Health Center
Hamilton Health Center (Hamilton), established in 1969, is the only
Federally Qualified Health Center (FQHC) within a 30-mile radius of
Harrisburg, PA and continues to grow using a holistic and
comprehensive approach to being patient centered. The mission of
Hamilton is to improve the health of Central Pennsylvania's
residents by delivering high quality, respectful and
patient-centered health and related social services that promote
access, treatment, education, and prevention regardless of health,
economic, or insurance status. Our vision is that every member of
our community, regardless of their ability to pay or their
insurance status, receives holistic, quality health care needed to
create a healthy community. For over 50 years we have been true to
these words. As part of our team, you will work alongside a
dedicated team that cares and values those we serve.
Benefits offered: In addition to your base pay, you are also
eligible to receive:
Paid time off, Catastrophic (CAT)/Sick time, Birthday holiday, and
7 paid holidays.
Medical, Dental & Vision,
Company paid life insurance.
Employee Assistance Program
Job Summary : The RN Care Coordinator is responsible for providing
efficient delivery of coordinated care in an ambulatory, primary
care clinic setting to defined patient populations through
collaboration with the patients, their family/caregivers, providers
(internal and external), insurers, and Hamilton staff. The RN Care
Coordinator is a member of the Patient Center Medical Home (PCMH)
care collaboration team.
This position shall drive assigned activities towards assuring
Hamilton meets federal and state regulatory requirements and The
Joint Commission quality improvement (QI) and performance
This position shall assist and/or drive, as assigned, but not
Peer orientation and ongoing training,
QI project support and coordination,
Patient safety and quality audits,
Assessment and analytical evaluation of QI effectiveness,
Identify opportunities for improvement in patient services and
outcomes (gaps in care closure),
Promote a culture of quality through demonstrated initiative,
accountability and professionalism
The RN Care Coordinator is responsible for case managing the
post-acute care of high-risk patients that are at risk for poor
health outcomes, non-adherent to best practice clinical guidance,
and demonstrating lack of self-management of primary and secondary
co-morbidities. This position will work with complex and varied
patients and situations. The RN Care Coordinator will identify
hospitalized high-risk, complex patients for program enrollment and
communicates with entities involved in the care of the patient to
promote and maximize care coordination.
Essential duties and Responsibilities :
CASE MANAGEMENT / CARE COORDINATION
Orients and educates identified high risk patients and
families/caregivers to the Center by: explaining RN Care
educating on the Patient-Centered Model of Care
evaluating patient's readiness to engage
involving them in collaborative care planning
reinforce the provider-directed care plan
providing educational information to facilitate understanding of
respecting patients by recognizing their rights and contributions
to care plan development
Co-manage identified high-risk patients through patient assessment
and coordination of care, which includes collaboration with the TOC
Care Manager, Chronic Disease Educator, Navigators and Behavioral
Health Team for home and hospital visits when necessary.
Develops interdisciplinary care plan and uses various case
management tools to support goal achievement and/or resolution of
barriers to care and service
Demonstrate and/or monitor delivery of care through documented
evidence of care delivery, and serving as point person for:
interacting with involved departments to negotiate and expedite
scheduling and completion of tests, procedures, and consults;
identifying progress toward established goals and intervening to
overcome deviations in the expected plan of care
engaging in interdisciplinary team meetings to support evaluation
of effectiveness of interventional care plan and implementing team
promoting use of patient portal to patient and family/caregiver to
support access to relevant information that supports
Carries out quality of life and functionality assessments, gaps in
care resolution, and coordination of care across the continuum.
Evaluates under- and over-utilization to reduce inappropriate
emergency room utilization and prevent hospital
Collaborate with the TOC Care Manager to facilitate timely
post-hospital clinical care, access to appropriate services, and
service referrals for specialty appointments.
Assure accurate reporting through defined metrics, tracking and
analysis as per Quality Department standards. Collects data and
uses results to develop required reporting.
BEST PRACTICE IMPLEMENTATION
The RN Care Coordinator utilizes research findings in practice and
participates in PCMH program design, implementation, and evaluation
and participates in ongoing quality improvement activities. The RN
Care Coordinator collects clinical path variance data that
indicates potential areas for system-wide improvement of care and
service. The RN Care Coordinator seeks to resolve errors and
discrepancies through a broader system approach.
Participates in the orientation of new department staff, students
Evaluates, implements, and evaluates comprehensive proven clinical
practice guidelines, expert guidance, and nationally recognized
research to support program evaluation that assure quality and
appropriateness of care across settings.
Delivers triaging patient evaluation according to current policy
and protocols, as needed.
Participate in the Hamilton's efforts related to revenue cycle,
which include but are not limited to achieving goals for
productivity; meeting or exceeding revenue targets; reduce care
gaps; improve UDS measures; and, adhering to expense management as
PROFESSIONAL DEVELOPMENT AND ENGAGEMENT
Maintains professional and technical knowledge by attending
educational workshops; reviewing professional publications;
establishing personal networks; benchmarking state-of-the-art
practices; participating in professional societies.
Work collaboratively with Quality Director in the development and
implementation of a quality management strategy and annual
Minimum Education/Certifications: Graduate of an accredited
registered nursing program, successfully completing state board
exams with a current license to practice as a Registered Nurse in
the Commonwealth of Pennsylvania, required.
Bachelor's degree preferred. Certification in Case Management (CCM)
Minimum Work Experience: Minimum of two years' experience working
with patients and families in a Community setting, Public Health,
Outreach, Social Work or related field with progressively more
responsible leadership experience, required. Prior experience with
care coordination/care management in a clinical setting is
preferred. Highly proficient in Microsoft Office and knowledge
working with Electronic Medical Records. Ability to clearly
communicate issues to all levels of management.
Knowledgeable in The Joint Commission regulations and bi-lingual
Spanish speaking, preferred.
Other Requirements: Reliable transportation to travel throughout
the service area.
This job description is a general outline of duties performed and
is not to be misconstrued as encompassing all duties performed
within the position. All individuals (including current employees)
selected for a position will undergo a background check appropriate
for the position's responsibilities.
Keywords: HAMILTON HEALTH CENTER INC, Harrisburg , RN Care Coordinator, Healthcare , Harrisburg, Pennsylvania
Didn't find what you're looking for? Search again!