Nurse Care Coordinator
POSITION: RN Care Coordinator
LOCATION: All Site (Lincoln, Lee, Medway & W. Enfield)
WORK SCHEDULE: Monday – Friday
SUMMARY: Assist in the overall management of patients, particularly those with chronic conditions.
RESPONSIBILITIES AND DUTIES:
- Provides care coordination to patients with chronic health conditions, special care populations (i.e. substance use disorder, homeless, diabetic, COPD, CHF, prenatal etc.) or at-risk populations for increased hospitalization or emergency room utilization.
- Consults with the patient’s primary care provider in coordinating plans of treatment and advocating for patients when necessary.
- Establishes a self-management plan that is mutually agreed upon by the health care team and the patient/family.
- Monitors and evaluates the progress of the patient in meeting established care goals.
- Makes referrals on patient’s behalf and follows up to ensure that services are in place and patient’s needs are met, and follow up with patients who have not kept important referrals / appointments.
- Identifies and effectively utilizes community resources to meet the needs of patients/families.
- Serves as a liaison to providers, patients and families for coordination of services.
- Works closely with HAN’s social worker to identify patients with psychosocial economic gaps.
- Utilizes reports to identify gaps in care and patients not accomplishing goals set forth. Goals are specified in the Maine PCMH pilot and meaningful use criteria.
- Assists other members of the care team with pre-visit planning.
- Performs initial and periodic holistic assessments for patients with chronic disease. Prioritizes patients according to intensity, need and required follow up.
- Performs individual or group based education, counseling, or self-management goal setting.
- Reviews self-monitoring results and incorporates them into the medical record.
- Provides training to patients on correct use of insulin, inhalers, etc.
- Participates in regular team meetings and peer review activities, and departmental and committees.
- Participates in ongoing education in the field of care coordination.
- Works effectively to provide a team-based approach in order to provide patients with quality care.
- Performs other duties as requested.
- Nursing degree required
- State of Maine RN license required
- Experience in community or home health preferred
- Must possess sound knowledge of nursing principles, procedures, and standards of practice as determined by state and federal regulations.
- Must be able to communicate articulately and comprehend written and verbal communications.
RESPONSIBLE TO: Medical Director
Interested candidates should click here and complete our online employment application AND forward a resume and cover letter to Sonia Maxwell, HR Director/Compliance Officer (firstname.lastname@example.org).
POST DATE: 08/29/2019