RN Care Coordinator - Ambulatory Care Coordination - Full Time

About the position - M - F 8 - 5pm

The Nurse Care Coordinator organizes team-based care planning to provide support and comprehensive health services to individuals, mainly focusing on individuals with higher risk and complex needs, through effective partnerships with patients, their caregivers / families, community resources, and their healthcare providers. Performs short term transitional care activities and longer-term care planning for complex patients through facilitation of a shared care plan across the continuum of care to achieve well-coordinated, timely, cost effective, high-quality care that is patient and family centered.

Responsibilities

• Manages a panel of active patients requiring complex care management and care coordination support
• Collaborates with the multidisciplinary team, including the patient and their family, to design and implement holistic individualized plans of care for patients enrolled in care coordination programs
• Communicates necessary and important information to physicians, supervisors, patients, and staff
• Assess patient and family's unmet health and social needs as well as health literacy and identifies strategies to resolve needs
• Provides care coordination support across settings and transitions of care including discharges from acute and post-acute settings, specialty settings and provider transitions

Requirements

Why You'll Love Us

Work Schedule : 8a-5p