RN Care Coordinator
Company: HAMILTON HEALTH CENTER INC
Location: Harrisburg
Posted on: July 28, 2022
Job Description:
All About Hamilton Health CenterHamilton 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.
- Retirement Plan
- Employee Assistance ProgramJob 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 measurement standards.
This position shall assist and/or drive, as assigned, but not
limited to:
- 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 professionalismThe 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 Coordinator role
- 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 care plan
- 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 recommendations
- promoting use of patient portal to patient and family/caregiver
to support access to relevant information that supports
self-management.
- 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
admissions/readmissions.
- 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
IMPLEMENTATIONThe 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 and interns.
- 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
budgeted.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
goals. 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) preferred.
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.
PI
Keywords: HAMILTON HEALTH CENTER INC, Harrisburg , RN Care Coordinator, Healthcare , Harrisburg, Pennsylvania
Didn't find what you're looking for? Search again!
Loading more jobs...