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RN Care Coordinator - Mobile Health

Company: Denver Health
Location: Denver
Posted on: May 6, 2021

Job Description:

Job SummaryUnder general supervision, the RN Care Coordinator is responsible for facilitating and coordinating the care delivered to an assigned group of patients through multidisciplinary and patient/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment, planning, support, and evaluation of patient care and related outcomes. Activities to be performed are facilitation of appropriate status and level of care, screening for high risk and transition of care needs, interviews with patient/family, progression of care facilitation with the healthcare team, performing insurance reviews and ensuring compliance with all state, federal and third party payors.Under general supervision, the RN Care Coordinator (RNCC) is responsible for facilitating and coordinating the care delivered to an assigned group of patients through multidisciplinary and patient/family collaboration to ensure quality and cost effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment, planning, support, and evaluation of patient care and related outcomes. Activities to be performed are facilitation of appropriate status and level of care, screening for high risk and transition of care needs, interviews with patient/family, and progression of care facilitation with the healthcare team. Encounters occur face to face, telephonically, virtually, and electronically with patients in clinic, at home, at school, and at work.In addition to care coordination activities, the RNCC for the Mobile Health Services Department also provides direct patient care, rotating between our mobile health centers. Is an active contributor in the development of systems (e.g. care maps, clinical paths) to improve the care of assigned patient populations. Helps ensure compliance with grant programs, state, federal and third party payor requirements.Responsibilities1.Systematically collect focused data relating health needs and concerns of patient, group, or population. 2.Establishes and maintains patient centered relationships. 3.Involve the patient, family, and other healthcare providers in making shared decisions about formulating expected outcomes and goals. 4.Analyze assessment data to determine the health promotion, health maintenance or health related problem needs and statements. 5.Identify expected outcomes in a plan of care individualized for a specific patient, group or population. 6.Develop a plan that identifies strategies and alternatives to attain expected outcomes. Utilize competent, evidence based, nursing interventions during visits, telephone encounters and electronic communications according regulatory requirements and standards, as well organizational policies and procedures. 7.Implement identified plan in partnership with patient, caregivers and other health care professionals in a timely manner. 8.Conduct systematic, ongoing, and criterion-based evaluation of outcomes of nursing care in relation to structures and processes prescribed by plan. 9.Include patient, care givers, healthcare team in evaluation process. 10.Document in readable, understandable language according to professional, regulatory, and agency standards. 11.Document and disseminate results of care to patient, caregivers, and others involved in the care or situation, as appropriate, in accordance with contractual requirements, state and federal laws, regulatory requirements, and Denver Health policy. 12.Coordinate the delivery of care within the clinic setting, throughout the organization, and across health care settings. 13.Delegate appropriate interventions to care team members based on demonstrated competency, state practice acts, evidence based guidelines, regulatory and governmental standards, and organizational policies with defined outcome measures. 14.Reevaluate and follow up on nursing delivered based on patient needs, patient request, and patient condition. 15.Provide relevant information across levels of care, within in Denver Health and with other healthcare systems and payers when patient care is transferred between and among different specialties and/or within one or more organizations. 16.Provide information to the health care team including the patient, family, and caregiver regarding available resources and benefits for health care services that ensures patient choice and safe, timely transition. Identify for patient and health care team situations that may negatively affect reimbursement or payer coverage. Advocate to secure benefits for patient care. 17.Identify and address avoidable delay practice patterns that may require modification to support cost effective care. Uses escalation process as needed. 18.Manages patient, family, caregiver expectations for short and long term goals based on health status, prognosis, and available resources. 19.Serve as point of contact within and among healthcare services and organizations. 20.Coordinate community resources as appropriate. 21.Assures designation of primary responsibility among team members for each aspect of care plan, avoiding duplication and fragmentation. 22.Facilitate continuity of care using the nursing process, multidisciplinary collaboration, and coordination of all appropriate healthcare services and community resources across the care continuum. 23.Orient patient/caregiver to health care delivery system, services, access, and resources. 24.Identifies barriers to goals and strategies to address 25.Provides personalized education for optimal wellness 26.Encourages preventative care such as immunizations and cancer screening 27.Reviews and educates on medication regimen 28.Promote appropriate utilization of resources 29.Assists and educates caregiver when member is unable to participate. 30.Incorporates health literacy, cultural, and language needs and preference into education and goals. 31.Support patients and caregivers in developing skills for self-efficacy to promote, maintain, or restore health such as healthy lifestyle tips, risk-reducing behaviors, age and developmental needs, activities of daily living, and preventative care. 32.Attain knowledge and competency that reflect current nursing practice. 33.Participate in ongoing, diverse educational activities related to ambulatory care nursing and health care knowledge. 34.Acquire knowledge and skills appropriate to ambulatory care nursing, specialty care, practice setting, role, or situation. 35.Proactively recognize the needs of others, using positive interactions and creative solutions to achieve effective outcomes. 36.Contribute to a positive, supportive, and healthy work environment that is conducive to the education and professional growth of nursing staff and other health care staff. 37.Respects and values the contributions of all disciplines. 38.Builds and maintains relationships that foster trust and confidence. 39.Works with team across continuum of care to identify patients in need of care coordination services. 40.Share knowledge and skills with peers and colleagues.41.Participate in the identification and resolution of ethical concerns, utilizing American Nurses Association Social Policy Statement and Code of ethics. 42.Preserve patient's rights to confidentiality, privacy, and self-determination within legal, regulatory, and ethical parameters. 43.Ensure patient care reflects the cultural, spiritual, intellectual, age, educational, and psychosocial differences of individual patients, families, groups, and communities. 44.Ensure that patients have opportunities to voice opinions regarding care and services received and have these issues reviewed and resolved, without fear of recrimination. 45.Project a therapeutic professional approach to patients, colleagues, and staff maintaining appropriate role boundaries. 46.Primary commitment is to the patient. Help individuals assume more of their own health promoting activities. 47.Utilizes ethics committee or other resource to resolve challenges or conflict regarding patient care. 48.Adheres to scope and standards of practice for Professional Ambulatory Care Nursing from the American Academy of Ambulatory Care Nursing and the Standards of Practice and Scope of Services from the American Case Management Association. 49.Other duties as assigned.Knowledge, Skills & AbilitiesKnowledge, Skills and Abilities 1. Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment required. 2. Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently. 3. Evidence of leadership, creativity, integrity and initiative required. 4. Ability to work effectively in a team environment.Experience: Three years of clinical inpatient experience required.Knowledge, Skills and Abilities: 1.Knowledge of Dental assisting and preferred Oral surgery assisting, patient record maintenance, patient registration, and billing. 2.Knowledge of safety guidelines, HIPAA and OSHA compliance. 3.Excellent interpersonal and customer service skills. 4.Ability to schedule patients using in house scheduling software. 5.Ability to deescalate patients/staff situations and handle complaints when necessary. 6.Ability to train/mentor staff. 7.Knowledgeable of budget principles by articulated, verbally and in writing, budget needs and variances. 8.Ability to perform duties of an Oral Surgery Assistant. 9.Knowledge of registration process, scheduling, fee schedule and insurance plans.Computers and Technology 1.Microsoft Office Suite 2.Experience with windows-based computer programs and ability to use computer for data analysis and data display required. 3.Prefer experience with EPIC documentation platform.Education Bachelor's degree in Healthcare Management or related field required. Experience 2.Five years of experience in a related role as a manager required.Credentials Active Registered Nurse (RN) License in the Sate of Colorado or a participating compact state.Basic Life Support for Health Care Provider Certification/CPR. Work TypeFull TimePay RangeMinimum: 65,048.46Midpoint: 83,539.02Maximum: 102,029.58All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver's 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.As Colorado's primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE)."Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class."

Keywords: Denver Health, Denver , RN Care Coordinator - Mobile Health, IT / Software / Systems , Denver, Colorado

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