RN Care Coordinator Clinic
Company: Advocate Aurora Health
Location: Sheboygan
Posted on: January 12, 2021
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Job Description:
In partnership with the patient and family, collaborates with
physicians and the inter-professional team to establish a plan of
care with targeted goals and interventions that lead to optimal
outcomes for identified at-risk populations. Maximizing the
patient's own self-care abilities, the Care Coordinator uses the
nursing process to assess, plan, implement and evaluate clinical
strategies leading to quality results, optimal costs/utilization
and patient experience. Works across the care continuum to support
patients in addressing the following dimensions of care: clinical
management, education/knowledge, psychosocial needs,
self-management, advocacy, and continuity of care. Establishes an
ongoing, therapeutic relationship with the patient/family to
improve access, reduce burden of disease, manage care transitions,
and increase use of appropriate access points for care.Partners
with identified at-risk patients throughout the diagnosis,
treatment and follow-up in order to deliver continuity of care.
Anticipates the needs of the patient, recognizes and responds to
changes in a patient's status and determines priorities of patient
care based on essential patient needs. Ensures necessary
documentation is complete.Collaborates with the patient/family and
inter-professional team in evaluating change readiness, assessing
patient's wants and needs, developing plan of care, designing
teaching plans/programs, promoting self-care skills, and evaluating
the patient's progress toward goals and expected outcomes.
Maintains a patient-centered, whole person approach to care.Serves
as a clinical resource to others by establishing clinical expertise
in management of assigned population and keeps up-to-date on
current evidence.Uses evidenced-based approaches to increase
patient and family activation and engagement in their own care. As
appropriate to the population, partners with patient and family to
develop SMART (specific, measurable, attainable, relevant,
time-bound) goals. Assists in the development, procurement, and
adoption of patient self-management educational
resources.Identifies potential barriers to learning and/or to the
optimal delivery of care. Reports abnormal findings to the
responsible provider/care team, and collaborates to develop a
plan.Facilitates appropriate and prompt access to primary care
providers, physician specialists and other services as needed.
Coordinates patient information and communication between and among
the patient/family, the referring/accepting facilities and
physicians, community caregivers (as applicable) to ensure smooth
transitions of care.Provides patients and families appropriate
community resources, as needed. Acts as a resource on care
coordination and as a patient liaison to providers, clinical staff,
other clinical services or facilities and the
community.Collaborates with Care Management to identify applicable
resources and previously identified best practices. Monitors
patient registries to identify patients overdue for visits, labs,
or referrals; arranges follow-up services as appropriate and
updates health information records.Conducts current and
retrospective clinical reviews for the purposes of determining best
practice patient care outcomes including most cost effective,
appropriate care for the patient, and the effectiveness of care
coordination. Coordinates timely, seamless, evidenced based care
across the care continuum resulting in best patient
outcomes.Communicates and collaborates with the local and extended
care team to ensure a smooth flow of information and teamwork.
Delegates technical activities that do not require a Registered
Nurse to perform to appropriate team members.Scheduled Hours Monday
- Friday in current stateLicenses & CertificationsRegistered Nurse
license issued by the state in which the team member practices.
Basic Life Support (BLS) for Healthcare Providers--certification
issued by the American Heart Association (AHA) needs to be obtained
within 6 months unless department leader has determined it is not
required. DegreesBachelor's Degree in Nursing. Required Functional
ExperienceTypically requires 5 years of experience in clinical
nursing that includes experience in nursing assessment, care plan
development and in educating patients.Knowledge, Skills &
AbilitiesWorking knowledge of the components of quality and patient
care needs specifically related to the area in which care will be
performed.Maintains clinical expertise to effectively manage
physical, emotional, psychosocial and spiritual needs of patients
throughout the care continuum. Excellent analytical and
interpersonal communication skills necessary to negotiate with
families, patient, physicians and third party payers. Demonstrated
ability to work well with physicians and other professionals in a
direct and positive manner.
Keywords: Advocate Aurora Health, Sheboygan , RN Care Coordinator Clinic, Healthcare , Sheboygan, Wisconsin
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