RN Care Coordinator - Seaford - Full Time - Day Shift Job Opening

Description:
Job Summary

• As a member of the care team, the Care Coordinator works to provide patient-centered care across the healthcare continuum while supporting Nanticoke Health Services’ efforts in population health management, the Patient Centered Medical Home (PCMH), ACO and community health outreach. The Care Coordinator works to organize and coordinate the management of the patient’s care by assisting with transitions of care, planning and implementing a patient centered care plan, and coaching/educating patients and caregivers to positive self-care management behaviors.
• Self-starter; able to work independently and develop programs with minimal direction.
• Project management skills including data management; use of clinical system design and population registries.
• Able to work within multiple Microsoft Applications (Office, Excel, Outlook).
• Excellent interpersonal, verbal communication, problem-solving, and organizational skills.
• Able to build and maintain relationships with patients, staff, providers, and community resources.
• Outstanding clinical and assessment skills.
• Able to coach/educate patient and caregiver in a culturally acceptable manner.
• Works with teams of providers and staff to coordinate care services.
• Works with referral sources to identify and facilitate services.

General Responsibilities

• Upholds the organizations' Mission, Values and Goals by adhering to the NHS Standards of Performance.
• Participates in team-based patient-centered care delivery.
• Performs clinical assessments, health coaching, disease education, care planning, community outreach, and service referrals with appropriate EHR documentation.
• Participates in and/or leads effective Interdisciplinary Team meetings with community partners.
• Assists in addressing barriers to effective self-management.
• Able to navigate in multiple healthcare database systems (EHR, HIE).
• Obtains and analyzes data and reports for quality improvement, PCMH reporting, and other data management.
• Supports implementation of care coordination and care management, identifies action plans to improve cost, quality, and the patient experience and participates in design, development, and implementation of community learning forums.
• Serves on various NHS Committees and other NHS projects as assigned.
• Collaborates with the PCMH team to meet provider and practice service needs.
• Collaborates with ACO affiliates to coordinate cost effective care of Medicare beneficiaries and maintains ACO reporting metrics.
• Actively participates or leads in developing program recommendations and action plans.
• Makes recommendations on office based care delivery interventions resulting in cost of care savings and/or improved health outcomes for patients.
• Promotes practice transformation to team based patient centered care delivery.
• Provides education for practices to develop expertise with metrics and data review for quality improvement.
• Actively participates in various community and multi-department committees to assure effective program implementation.
• Tracks progress of program and prepares status reports to management and/or senior management.
• Maintains up to date knowledge on PCMH and Care Delivery System Redesign.
• Demonstrates a thorough knowledge of his/her key responsibilities.
• Ability to travel within the region.
• Other duties as assigned.

Requirements:
Work Experience:

• 3-5 years of acute care experience or Case Management experience
• Discharge planning, case management, disease management experience, and/or prior experience working in public health organizations
• Experience with electronic health record is strongly preferred
• Outpatient or home health experience is beneficial Experience with and knowledge of PCMH standards is beneficial

Education Requirements:

• Current licensure to practice in the State of Delaware as a Registered Nurse (RN) (BSN preferred) or Licensed Social Worker (LCSW) / Bachelor’s Social Work (BSW) will be considered.
• Current licensure to practice in the State of Delaware and/or Compact State Licensure to work in the state of Delaware as a Registered Nurse
• Current CPR certification required
• Obtain Certification in Care Coordination and Transition Management within 2 years of date of hire Must meet all applicable federal, state, and local professional requirements