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RN Care Coordinator

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.


Keywords: HAMILTON HEALTH CENTER INC, Harrisburg , RN Care Coordinator, Healthcare , Harrisburg, Pennsylvania

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