RN Care Coordinator - Richwood Primary Care

Job Summary

Reports to the RN Manager of Care Coordination, the RN Care Coordinator (OCC) works collaboratively with providers, interdisciplinary staff, and clinical associates, in person and telephonically, at any/all SEP offices to support patients with chronic conditions and/or complex needs according to guidelines established by SEP and other clinical programs such as PCF etc. Facilitates effective communication, coordinates services, addresses barriers, and provides education and guidance for patients related to current health concerns.

Regular

40

• Documents in chart appropriately utilizing care management documentation.
• Provides patient care through collaborating with patients, providing education and clear direction to the patient and addressing patient concerns regarding care. The RN engages in critical thinking to meet patient needs.
• Support Chronic Disease Management and Patient Care Needs:
• Identify patients with chronic disease, rising risk concerns, social, financial, or educational needs for care management services.
• Respond to provider referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or blood pressure, Mental Health Integration referral, complex needs)
• Evaluate and collaborate with patients and families to determine readiness to change and resources for support.
• Monitor compliance with plan of care and problem solve barriers to patient self‑management.
• Provide support for patient and family issues, resource needs, and answering general healthcare questions.
• Do ADL assessment and home safety assessments based on patient interview.
• Identify and place order for services such as HH when patient has identified need.
• Utilize teach back method for pts who have no medical necessity to justify home health.
• Assess need and provide basic diabetic teaching (glucose meter testing, etc.).
• Assess need and obtain required order for patient to receive disease management teaching or counseling (MD referral required for billing).
• Document RN Care Coordinator interventions in Epic within care management documentation.
• Refer non‑nursing functions, such as assisting patients with completion of Medicaid, disability, pharmacy program or other eligibility applications, and scheduling appointments to designated resources in the region.
• Coordinate with care managers in other settings as appropriate.
• Carry out assessments and make decisions on his or her own before seeking the support of a supervisor.
• Assist providers, patients, and families with Advance Care Planning.
• Explain results from screening based on protocol and guidelines.
• The RN is expected to perform medication reconciliation for each patient on their panel.
• Provides ongoing management for chronic conditions, working with patients to meet healthcare goals per cadence expectations.
• Patient
  
  Education:
• Provide education and pre‑printed, SEP approved educational materials as needed, or at provider or patient request.
• Work collaboratively with patients to assess needs and develop a patient education plan of care.
• Answer clinical questions related to patients chronic health conditions.
• Provide group education for established patients.
• Must understand professional boundaries and appropriately refer diagnostic questions to MD.
• Refer patients appropriately when needs for mental health, pharmacy, social work, respiratory therapy etc. are identified.
• Work telephonically with patients as needed.
• Ensures complete and accurate information in the Electronic Health Record.
• Coordinate referrals to community resources (e.g. home health, Durable Medical Equipment, support groups).
• Forward written physician orders for treatment.
• Assess patient for additional needs, develop nursing plan of care and contact physician for order‑dependent items.
• Coordinate scheduling of appointments when support is needed for a multitude of disciplines.
• Maintains adequate level of resources for care coordination.
• OSHA and HIPAA compliance.
• Assists with completion of patient requests in a timely manner.
• Timely and accurate complete charting of all patient information.
• Other duties and responsibilities as…