JOB SUMMARY:

The RN Community Care Coordinator manages individualized patient centered goal directed Nursing Care through use of the Nursing Process and the principles of Primary Nursing in accordance with Departmental and hospital policies and procedures. Provides care coordination/management for patient populations, including but not limited to MDPCP identified patients, with the ultimate goal of improved health, reduced health care costs, and better coordination of care. The RN Care Coordinator accepts care management referrals; maintains assigned caseload (50-75). The RN Care Coordinator utilizes evidence-based medicine, data analytics and innovation in implementing care management principles, and applies critical thinking skills and leadership skills in working with the team to meet patients and their families’ needs. The RN Care Coordinator is assigned to manage a panel of patients, and working together with primary care Interdisciplinary Teams (IDT), is responsible for coordinating care to obtain desired health outcomes, improve self-care abilities, decrease cost of care, and provide extraordinary patient care in the process. The RN Care Coordinator guides the Team in utilizing evidence-based medicine, data analytics and innovation in implementing care management principles, and applies critical thinking and leadership skills in managing the Team to meet patients and their families’ needs. The RN Care Coordinator understands and applies principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and adjusts patient assignments accordingly.

The RN Care Coordinator works predominantly within Practice Groups to deal with the increasing complicated chronic disease patient with multiple co-morbid conditions, highest acuity and most complex of needs. The RN Care Coordinator interfaces with providers within the practice groups, nurses, all departments within the hospital facilities, and community resources to expedite medically appropriate cost-effective care. The responsibilities as the primary RN Care Coordinator includes but are not limited to: performance of standardized comprehensive needs assessment, determination of available benefits and resources; and development and implementation of a plan of care for assigned patients that includes performance goals, monitoring, follow-up and outreach activities. Patients assigned to RN Care Coordinator can include but are not limited to: complex patients whose critical event or diagnosis require extensive use of resources, and who need help navigating the system to facilitate appropriate delivery of care and services; transitional care management focused on evaluating and coordinating post-hospitalization needs of patients at risk for rehospitalization, and high risk, high cost patients who frequently use emergency department services or have frequent hospitalizations.

The Plan of Care is created based on the results of the comprehensive needs assessment performed by the RN Care Coordinator through extensive medical record review, face to face and/or telephonic encounters with assigned patients and families where appropriate. Performance goals are focused on resolution of critical events, control of chronic disease, decrease avoidable admissions and readmissions; safe care transitions, improvement in self-management skills while providing extraordinary patient experience.

• Outreach and health promotion services.
• Comprehensive assessment with required documentation.
• Coordination of referrals and transitions of care from one provider to another or from one care-setting to another.
• Medication reconciliation and adherence.
• Facilitation and/or procuring timely access to appointments and services required by patient.
• Patient and Family/Caregiver education.
• Evaluation of effectiveness of care plan with IDT Essential Job Functions.

REQUIREMENTS:

• Seasoned professional knowledge; Graduate of an Accredited School of Nursing; Bachelor’s Degree required (BSN). Master's Degree preferred.
• Current valid Registered Nurse License (RN) in the State of Maryland (or Compact State as applicable).
• Case/Care management certified or knowledge of national care management standards and community resources is a plus.
• 3-5 years demonstrated proficiency in acute care nursing, knowledge and skills.
  • Preferably with care management experience from acute care setting or health insurance and other payer entities.
• High level verbal and communication skills and organizational skills a must.
• Strong analytical, data management and computer skills.
• Competency in electronic medical records desirable.
• Previous ambulatory and population health experience helpful.