POSITION SUMMARY:
The RN Care Coordinator provides a deliberate patient and family centered partnership with the healthcare team that facilitates a seamless patient experience between the Inpatient and Outpatient settings and coordinates patient care through the continuum thereby facilitating the achievement of optimal quality outcomes in relation to clinical care and cost effectiveness; develops and supports a coordinated plan of care between visits to promote a smooth transition for patients and family across the healthcare continuum that instills a sense of trust and patient advocacy; facilitates the achievement of optimal quality outcomes in relation to clinical care and cost effectiveness; provides patient/family education pertinent to health conditions and wellness need; provides patient care activities through the nursing process including, but not limited to, assessment, planning care, implementing physician orders, providing education pertinent to health conditions, coordinating patient care, evaluating patient responses to interventions, revising care plans as indicated and maintaining a therapeutic environment.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
NON-ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Performs other duties and tasks as assigned.
GENERAL EXPECTATIONS:
- Be committed to the mission of the Bucksport Regional Health Center.
- Work as a member of the medical team in the performance of duties.
- Be punctual for scheduled work and use time appropriately.
- Work in harmonious relationships with all staff, patients, vendors and others.
- Perform duties in a conscientious, cooperative manner.
- Perform required amount of work in a timely fashion with a minimum of errors.
- Be neat and maintain a professional appearance.
- Maintain confidentiality and protect the Center by keeping information concerning Operations, patients and employees confidential.
- Demonstrates professionalism as well as respect, honesty, dignity, and caring behaviors for the patient/family and all members of the health care team.
- Demonstrates courtesy, respect and caring to patients, families, physicians and staff, and maintains professional rapport with all.
- Participation in community activities as a representative of Bucksport Regional Health Center.
Requirements
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Coordinates and manages patient care for high risk and complex patient populations across all elements of the Healthcare System and Patient’s Community; coordinates and performs the duties of disease care coordination utilizing the components of the nursing process:
- Assessment, planning, implementation, coordination, monitoring and evaluation of the individually assigned patients.
- Prioritizes patient assignments according to the intensity of the needs and required follow-up.
- Identifies patients in need of care management services by utilizing generated reports to identify patients that require care management and collaborating with providers and practice staff to identify patients appropriate for care management.
2. Uses Risk Stratification protocols to identify high risk and complex patient populations through the use of Disease Registries, Information Technology and Health Information Exchanges.
3. Works with patients/families to develop an individualized plan for maximizing each patient’s ability to adhere to a health plan formulated with healthcare professionals; supports the patient in Disease Management and Health Maintenance.
4. Documents accurately and timely initial and ongoing assessments, including care plan development and evaluation and maintenance of any established database.
5. Uses education standards and tools for common conditions/issues seen in primary care; maintains education tools in collaboration with other continuing care services; provides patient/family education pertinent to disease progression, health status, wellness need and relevant therapies; tracks outcomes and progress on a regular basis.
6. Develops, maintains, and updates community resource data base for patient self-management support; maintains relationship and referral based with the community care team staff.
7. Communicates with external healthcare professionals as appropriate, informing them of the patient’s progress and any potential concerns related to their plan of care and clinical pathway.
8. Collaborates with and communicates with multidisciplinary care team to provide continuity of care and maintain standards between entities.
9. Provides advanced nursing care independently in physician practices utilizing advanced clinical knowledge and skills with particular emphasis on patient care needs, educational activities and anticipatory care needs for acute and chronic patient care. Provides and evaluates comfort interventions using competent nursing actions.
10. Manages acute and complex clinical situations with evidence of advanced knowledge/skills.
11. Manages complex telephone communication for patients with health problems and utilizes appropriate resources to guide practice.
12. Collaborates with physicians and staff as needed to provide comprehensive health care to the patient and to reinforce physician’s instructions, promoting continuity of care throughout the healthcare system.
13. Documents nursing actions and patient’s responses in complex situations using proficient logic; uses advanced EMR features to document nursing care.
14. Actively participates in workflow redesign with Care Team and acts as a clinical resource and mentor to other clinical staff. Promotes team efficiencies within the organization.
15. Identifies issues and implements process improvement to maintain a positive work environment.
16. Implements methods to improve communication with patients/family members.
17. Complies, promotes and monitors safety and emergency procedures consistent with policies and procedures.
18. Assists with monitoring, assessing, implementing and evaluating quality assurance measures.
PHYSICAL REQUIREMENTS:
The physical requirements described here are representative of those that must be met by the Incumbent to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is frequently required to stand; walk; sit; use hands to finger, handle, or feel, including operation of a standard computer keyboard; reach with hands and arms and talk, see and hear. Eye hand coordination and manual dexterity required. The employee must regularly lift/move up to 25 pounds, including assist with moving patients, as well as bend, stoop, stretch or crouch. Specific vision abilities required by the job include close vision, distance vision, and the ability to adjust focus.
WORK ENVIRONMENT:
The work environment characteristics described here are representative of those the incumbent encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Work is performed primarily in a typical physician's office environment. Noise level is usually quiet.
Potential exposure to hazardous and infectious materials, including blood borne pathogens.
QUALIFICATIONS NEEDED FOR POSITION:
Experience and Skill Requirements: The following experience and skills are considered essential:
- 1 year of nursing experience, preferably med-surg, critical care or ambulatory
- Experience in care planning, resource management or care management desired.
- Prior experience in primary care desired.
- Good time management, organizational skills, and critical thinking skills.
- Proven experience with an EMR, keyboarding and computer skills.
- Demonstrates excellent interpersonal and communication skills and the ability to manage conflict and develop relationships across organization lines using interpersonal communication skills.
- Ability to assess, plan and implement care plan
- Excellent assessment and patient education skills
- Ability to read, interpret, and apply clinic policies and procedures.
- Ability to identify problems and recommend solutions.
- Ability to establish priorities and coordinate work activities.
- Detail-oriented.
- Empathy for patients and their families.
- Ability to deal with stress.
Education Requirements: The following education requirements are considered essential:
- Graduation from an accredited school of nursing.
- Current registration as a registered nurse in the State of Maine.
- Current BLS certification.
** All requirements and skills are considered to be essential, unless otherwise indicated. **