The Temporary RN Patient Care Coordinator will work on a multidisciplinary healthcare team in a primary care setting, focused on coaching and coordination of care. Promote patient-centered care, frequent contact with primary care providers and medical home team members. This is a key role in the transformation of the medical practice into a Patient-Centered Medical Home.
Care Transition Coaching and Coordination
Develop relationships with hospital admission offices, case managers, discharge planners and ER contacts.
Work to develop processes and initiatives to engage these entities in relevant case management activities with each patient of the PCMH to ensure that all necessary post discharge needs are met: Monitor to ensure care is coordinated with home care agencies, specialists, or other resources.
Provides for continuity of care through collaboration and coordination of services with inpatient/outpatient health care teams.
Provides guidance, counseling and teaching to patient and family with regard to nature and course of illness, treatment and general health promotion throughout therapy and follow-up care. Oversees all learning materials for patients/families.
Track follow-up visits and care with appropriate specialists for complex patients.
Coordinate necessary referrals and authorizations.
Work with Physician, Office staff, and Clinical Reporting (Informatics) to help identify high risk, high need, and potentially high cost patients.
Collaborate with care team to ensure patient adherence to medical plan of care, including all appropriate preventative and disease-specific screenings, interventions, treatment goals including self-management goals, contact schedules.
Determine that screening tests are up to date, review test results and ensure action taken on abnormal testing.
Track performance of clinical outcomes.
Behavioral Health Support
Ensure patients are receiving appropriate behavioral health screening (depression / substance abuse) and behavioral health interventions
Facilitate necessary follow-up with local behavioral health providers.
Knowledge and Skills:
Requires knowledge of health care contracts and benefit eligibility requirements.
Requires knowledge of hospital structures and payment systems.
Pursues advanced and continuing education to maintain and further develop knowledge in current concepts of clinical nursing and applied science, as well as keeping practices current.
Able to perform and interpret EKG tests, venipuncture and waived lab tests.
Schedule: Monday-Friday 8:30am-5pm
Graduate of an accredited school of nursing, and currently licensed to practice as a Registered Nurse in the state of NJ.
Bachelor of Science in Nursing preferred.
Minimum of 3-5 years of direct patient care experience required
Certified Case Management (CCM) certification preferred
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.