RN COORDINATOR - Integrated Health Collaborative

RN COORDINATOR - Integrated Health Collaborative

PURPOSE OF POSITION

The Integrated Health Collaborative (IHC) RN Care Coordinator manages defined populations by using a collaborative process of assessment, planning, implementation and evaluation. The goals of this role are to engage, educate, and promote / influence patient decisions related to achieving and maintaining optimal health outcomes. The RN Care Coordinator uses a combination of proactive methods including : telephone calls; hospital, physician office and home visits to patients who are managed by the IHC Accountable Care Organization (ACO) that have been identified as needing care management. The RN Care Coordinator develops ongoing supportive relationships with all members of the Care Team and beneficiaries.

RESPONSIBILITIES & EXPECTATIONS

• Ensures consistent use of an initial Health Risk Assessment (HRA) for patients eligible for care coordination.
• Conducts initial visit with more comprehensive HRA as needed to assess the level of care coordination / management needed.
• Understands the role and use of clinical protocols and standing orders for chronic disease management.
• Collaborates with other team members as appropriate to co-manage.
• Utilizes a variety of educational material, intervention techniques, and community resources to engage patients, increase their motivation to change, and support patients in establishing behavior modification goals and implementation of care plan to meet those goals.
• Collaborates with patients and providers in the creation, review and updating of the plan of care.
• Establishes a follow-up schedule and monitors patient progress.
• Effectively and accurately utilizes the Electronic Health Record (EHR) and other IT tools to document and track patient history.
• Maintains accurate and up-to-date records and standardized data on all patients.
• Effectively communicates with the patient, PCP, team members as needed and any external providers, on the patient engagement and care plan status.
• Develops a maintenance plan with patients, when appropriate, to help them maintain a healthy lifestyle and prevent a reoccurrence of symptoms of their chronic condition (s).
• Collaborates with care teams to implement evidence-based protocols and methods for primary care ACO patients.
• Supports key IHC committees and performance meetings as assigned.
• Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the team's achievement of goals, and to help foster a positive work environment.
• Other duties as assigned.

JOB REQUIREMENTS

Preferred Skills / Knowledge

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, or veteran status.

WORKING CONDITIONS :

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