RN Care Coordinator Clinic - Military veterans preferred

In partnership with the patient and family, collaborates with physicians and the inter-professional team to establish a plan of care with targeted goals and interventions that lead to optimal outcomes for identified at-risk populations. Maximizing the patient’s own self-care abilities, the Care Coordinator uses the nursing process to assess, plan, implement and evaluate clinical strategies leading to quality results, optimal costs/utilization and patient experience. Works across the care continuum to support patients in addressing the following dimensions of care: clinical management, education/knowledge, psychosocial needs, self-management, advocacy, and continuity of care. Establishes an ongoing, therapeutic relationship with the patient/family to improve access, reduce burden of disease, manage care transitions, and increase use of appropriate access points for care.Partners with identified at-risk patients throughout the diagnosis, treatment and follow-up in order to deliver continuity of care. Anticipates the needs of the patient, recognizes and responds to changes in a patient's status and determines priorities of patient care based on essential patient needs. Ensures necessary documentation is complete.Collaborates with the patient/family and inter-professional team in evaluating change readiness, assessing patient's wants and needs, developing plan of care, designing teaching plans/programs, promoting self-care skills, and evaluating the patient's progress toward goals and expected outcomes. Maintains a patient-centered, whole person approach to care.Serves as a clinical resource to others by establishing clinical expertise in management of assigned population and keeps up-to-date on current evidence.Uses evidenced-based approaches to increase patient and family activation and engagement in their own care. As appropriate to the population, partners with patient and family to develop SMART (specific, measurable, attainable, relevant, time-bound) goals. Assists in the development, procurement, and adoption of patient self-management educational resources.Identifies potential barriers to learning and/or to the optimal delivery of care. Reports abnormal findings to the responsible provider/care team, and collaborates to develop a plan.Facilitates appropriate and prompt access to primary care providers, physician specialists and other services as needed. Coordinates patient information and communication between and among the patient/family, the referring/accepting facilities and physicians, community caregivers (as applicable) to ensure smooth transitions of care.Provides patients and families appropriate community resources, as needed. Acts as a resource on care coordination and as a patient liaison to providers, clinical staff, other clinical services or facilities and the community.Collaborates with Care Management to identify applicable resources and previously identified best practices. Monitors patient registries to identify patients overdue for visits, labs, or referrals; arranges follow-up services as appropriate and updates health information records.Conducts current and retrospective clinical reviews for the purposes of determining best practice patient care outcomes including most cost effective, appropriate care for the patient, and the effectiveness of care coordination. Coordinates timely, seamless, evidenced based care across the care continuum resulting in best patient outcomes.Communicates and collaborates with the local and extended care team to ensure a smooth flow of information and teamwork. Delegates technical activities that do not require a Registered Nurse to perform to appropriate team members.Scheduled Hours Monday - Friday in current state Licenses & CertificationsRegistered Nurse license issued by the state in which the team member practices. Basic Life Support (BLS) for Healthcare Providers certification issued by the American Heart Association (AHA) needs to be obtained within 6 months unless department leader has determined it is not required. DegreesBachelor's Degree in Nursing. Required Functional ExperienceTypically requires 5 years of experience in clinical nursing that includes experience in nursing assessment, care plan development and in educating patients.Knowledge, Skills & AbilitiesWorking knowledge of the components of quality and patient care needs specifically related to the area in which care will be performed.Maintains clinical expertise to effectively manage physical, emotional, psychosocial and spiritual needs of patients throughout the care continuum. Excellent analytical and interpersonal communication skills necessary to negotiate with families, patient, physicians and third party payers. Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.