RN Care Coordinator Outpatient

Newport News, Virginia

Overview

The RN Outpatient Coordinator works under the supervision of the Care Management Leadership and is responsible for the coordination of care to patients who are considered high risk with complex medical and psycho-social needs.

The Outpatient Coordinator strives to promote coordinated care in order to improve outcomes, efficiency in utilization of health care services by performing the following core functions : a) Assessment : Identification of patients for case management;

comprehensive collection of patient information and medical status; and continued evaluation of an established plan of care b) Planning : Collaboration with the patient, family / caregiver, primary provider, community partners and other members of the health care team for developing an effective plan of care c) Facilitation : Care coordination and communication among all involved parties d) Advocacy : Support for the patient and family / caregivers to ensure identified education and appropriate, timely care is received.

The position requires a high degree of flexibility, independence and willingness to participate in multiple activities with local travel.

The Outpatient Coordinator must have strong communication skills and the ability to converse comfortably with patients, caregivers, physicians, community partners and the interdisciplinary team.

What you will do

Develops an appropriate patient-specific Care Plan to include short and long term goals, objectives and actions and partners with the patient and family in the development of the plan of care.

Coordinates, collaborates, and obtains approval of the plan with the patient, family / caregiver, primary provider and other members of the healthcare team.

Guides the patient and family / care giver through the healthcare system, maximizing use of resources. Coordinates and executes the plan of care, optimizing access to appropriate services.

Ensures necessary referrals are ordered by the appropriate discipline and coordinated. Serves as an advocate for, and ensures education is provided to, the patient and family / caregiver as required.

Collaborates with the patient’s PCP and specialists in the development of the plan of care to ensure the patient’s needs are addressed;

communicates care objectives to appropriate individuals / departments / referral sources. Promotes adherence to the Care Plan for improved healthcare outcomes.

Proactively identifies and evaluates patients and families for care management from a variety of sources such as RHS internal reports, discharge / disposition planning, referrals, the healthcare system, employers and facility staff.

Assess and document clinical and psychosocial patient needs. Conducts systematic, on-going, thorough collection of patient’s physical, emotional, psychological, social and medical status and information via direct patient contact and other relevant sources such as professional and non-professional caregivers, medical records, family / caregiver interviews.

Reviews the patients’ health insurance benefits to determine services available. Evaluates the quality and necessity of health care services and makes recommendations for an alternative level of care when appropriate.

Execution of the interventions established that lead to accomplishing the goals set forth in the plan of care. Ensures coordination of care delivery processes, to include alternate healthcare settings and the home environment, for the purposes of enhancing the patient's health and wellness, safety, productivity, and quality of life, and for providing the most beneficial, cost-effective health care.

Develops, utilizes and maintains a variety of community resources to optimize access to services and medical care. Utilizes appropriate patient education materials.

Ensures timely and appropriate provision of services. Anticipates the patient’s needs and encourages patients and families to actively participate in the plan of care.

Establishes working relationships with referral sources and community resources.

Documents and updates the Care Plan as needed. Maintains documentation and data collection in accordance with RHS policies and procedures.

Conducts and / or participates in program evaluation as directed. Monitoring and evaluation may include, but is not limited to : patient's adherence and response to the treatment plans, timeliness or patient and family / caregiver contact and follow-up, identification of variances, patterns or trends from established practice guidelines and / or standards, established outcome measurement, results of interventions and treatment delivery and timeliness.

Performs a handoff with other AHC RNs when changing shifts and / or rotations of call. The handoff includes transferring of equipment (phone, ipad or laptop, supplies, etc.

as well as reporting current condition and needs of high risk participants for after hours care.

Qualifications

Education

Nursing (Required)

• Associates Degree, Sociology / Social Work / Nursing (Required)
• Bachelors Degree, Sociology / Social Work / Nursing (Preferred)

Experience

• 1-3 years Acute care nursing (Required)
• 1-3 years Case management and health care delivery experience (Preferred)

Licenses and Certifications

• Registered Nurse (RN) - Virginia Department of Health Professions (Required)
• CPR / BLS Certification - American Heart Association / American Red Cross / American Safety and Health Institute (AHA / ARC) (Required)
• Accredited Case Manager (ACM) - American Case Management Association (ACMA) (Preferred)
• Driver's License (Required)

To learn more about being a team member with Riverside Health System visit us at .