Care Coordinator RN PRN

Job Title & Specialty Area:
Care Coordinator RN PRN

Department:
Enterprise Care Management

Location:

Dallas

Shift: This position is PRN and requires 2 days of availability per week as well as holiday coverage.

Job Type: On-Site

Summary

Utilizing advanced nursing skills and knowledge, the Care Coordinator is responsible and accountable for coordinating care throughout the continuum of care for an assigned patient population. In partnership with the patient, family, and other care givers, the Care Coordinator will work with the multidisciplinary team, Providers, Nurses, Social Workers, financial counselors, and other ancillary staff to actively facilitate those functions associated with moving the patient through the continuum of care.

This role will support the continuity of care across the continuum by advocating for the needs of the patient and family and working with identified care team members to promote access to care, facilitate communication and provide effective resource coordination during care transitions to ensure continuity, quality and closure of gaps in care. Identifies and implements initiatives and opportunities to improve processes.

• Responsible and accountable for prescribing, delegating and coordinating patient care. Uses clinical judgment based on nursing skills acquired through formal and informal experiential knowledge and evidence based guidelines to globally assess the patient's situation and through critical thinking and clinical decision making, develop an appropriate plan of care for the patient, with the aim of promoting best outcomes.
• Accountable that patient care meets standards of safety, effectiveness, patient rights and guest relations.
• Oversees care delivered by patient care team; coordinates plan of care.
• Provides education and facilitates learning for patients, families, and patient care team in a way that demonstrates a sensitivity to recognize, appreciate, and incorporate differences related to diversity.
• Collaborates with physicians, families and other healthcare professionals to assist in developing and implementing an appropriate plan of care in a way that promotes/encourages each person's contributions towards achieving the best patient outcomes.
• Advocates for the patient, represents the concerns of the patient/family and identifies and assists in resolving ethical and clinical concerns.
• Will deliver care with a team-orientation, an emphasis on good customer relations, sound clinical judgment and appropriate decision-making abilities that take into consideration evidence based practice.
• Maintains a body of knowledge and tools that allow the nurse to manage whatever environmental and system resources exist for the patient/family, within or across healthcare and non-healthcare systems.
• Care Coordination / Disease Management:
  Completes and analyzes comprehensive assessment with patient intake
• Treatment plan coordination and management to include payors, supplies and equipment, medications, in-house services, other healthcare facilities and community resources/entities
• Collaborates with the health care team on the plan of care, referrals and ongoing needs of the patients
• Ensures consults, testing and procedures are sequenced in a manner that is appropriate to the patient's clinical condition and supports timely and efficient care delivery. Intervenes, resolves or escalates where barriers to service exist
• Utilize disease-specific clinical pathways to ensure effective clinical / disease management
• Assess the educational needs of patients, families, and caregivers taking into consideration barriers to care (e.g., literacy, language, cultural influences, comorbidities)
• Ensure that education regarding the clinical / disease process has been provided by the health care team
• Coach patients/families toward lifestyle changes and successful self-management of their chronic disease
• Demonstrate customer-focused interpersonal skills, utilizing problem-solving processes and critical thinking
• Facilitates communication and coordination of the plan of care with the Providers and the health care team
• Involvement in the development of strategies and plans to maximize the…