Registered Nurse Care Coordinator - Care Management

JOB PURPOSE: The Registered Nurse Care Coordinator promotes the mission and vision of El Rio Health through collaborative interdisciplinary teamwork to provide high quality nursing care, patient safety and care coordination in order to optimize health and minimize the use of tertiary care services. The Registered Nurse Care Coordinator leads disease management and disease prevention activities. Disease management activities include case management, referral coordination, and hospital/emergency department follow-up for high risk/complex patients. The Registered Nurse Care Coordinator will also develop strategies to assess for social determinants of health and measure patient experiences. This position will contribute to the integrated care team’s activities around process improvement, workflow design, and training, allowing staff to work at the top of their licensure and skill set.

Essential Job Functions:

• Identifies patient meeting criteria for care coordination (i.e., multiple chronic conditions, repeated health crisis, high social risk) through risk stratification and provider referral.
• Engages patients in care coordination.
• Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.
• Develops a comprehensive individualized plan of care and targeted interventions that involve patient/family in the decision-making process. Includes patient’s goals, preferences, and care team’s treatment goals.
• Continually monitor’s patient/family response to plan of care and revise as needed.
• Provides self-management support with a focus on empowering the patient/family to build capacity for self-care, providing resources and education, as necessary.
• Coordinates patient care through ongoing collaboration with provider, patient/family, community, and other members of the healthcare team. Fosters a team approach and includes patient/family as active members of the team.
• Provides follow up with patient/family when the patient transitions from one setting to another. Completes timely follow up including medication reconciliation/adherence, specialist follow up, teaching and problem-solving barriers.
• Performs medication management with ongoing medication regimens and develops a patient directed self-management strategy for compliance.
• Maintains an updated list of community resources.
• Maintains required documentation, including documenting preventative care and services performed elsewhere.
• Conducts follow-up phone calls to patients to ensure they are meeting their goals and status of managing their health issues. Oversees efforts and staff (i.e., medical assistants or other staff) responsible for coordination of prevention activities.
• Using data systems to monitor gaps in care.

• Monitors EMR tasks and messages to assure timely management and response to patient/family and provider concerns and requests.

•  Provides a work environment safe and free from hazards; immediately address or inform management of safety issues or potential hazards; adhere to Health and Safety Policies and Procedures; participate in all safety programs, which may include assignment to an emergency response team.

• Maintains a clean, safe, and hygienic work environment in compliance with all Policies and Procedures to include, but not limited to work areas, workstations, hand washing, infection control etc. as required for a Registered Nurse.

• Maintains patient confidentiality by controlling the environment and information being disclosed to authorized individuals ensuring HIPAA and corporate compliance requirements at all times.

• Maintains a clean, safe, and hygienic work environment in compliance with all Policies and Procedures including but not limited to work areas, workstations, examination rooms, hand washing, infection prevention and control etc. for this position
• Demonstrates an understanding of and proficiency with the application of all compliance and reporting requirements respective to Joint Commission Certification (JCC) standards.

• Consistently demonstrates AIDET principles and serves as a role model for service excellence with all patients/visitors, colleagues, and the community.

• May make home visits as needed and approved by supervisor.

• Embraces and promotes a professional working environment based on understanding and respect for diversity and multi-culturalism in all of its forms; demonstrate sensitivity, acknowledge varied beliefs, attitudes, behaviors, and customs, and encourage communication and appreciation of all forms of diversity.

Minimum Education and Experience:

• A Degree or Diploma as a Registered Nurse from an accredited school of nursing, college, or university.
• One (1) year experience with hands-on patient care nursing, either in a hospital or clinic setting.

If applicable, equivalent combination of education and experience may be considered, and must be directly related to the functions and responsibilities of the job.

Required Licenses, Certifications, and Registrations:

• Current Registered Nurse license in good standing from the Arizona Board of Nursing.
• Current certification in Basic Life Support (BLS) for health care providers
• Level I fingerprint clearance card: current valid and in good standing or have applied for it within seven working days after beginning employment.
• Employees in this position are required to have reliable transportation that can meet any operational reassignments of the organization during the workday. If an employee is driving during work hours, the employee is required to possess a valid driver’s license and must comply with Arizona vehicle insurance requirements.

Preferred Education, Experience, Skills, Abilities:

• Three  (3) years’ experience with hands-on patient care nursing, either in a hospital or clinic setting.

• Three (3) to five (5) years’ nursing experience in an inpatient setting (i.e., Emergency Room, Critical Care, Medical/Surgical)
• Experience in a fast-paced community health center.
• Care Management experience.
• Experience in continuous quality improvement.
• Strong telephone skills.
• Bilingual (English/Spanish) with the ability to speak, read and write in both languages.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

El Rio Health does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity or expression, age 40 and over, disability, genetic information, military status, ancestry, marital status, familial status, or any other status protected by law or regulation.

It is our intention that all qualified applicants be given equal opportunity and that selection decisions are based on job-related factors.

All employees are required to undergo drug testing prior to employment and, will be subject to post-accident, reasonable suspicion, return to duty and follow up drug and alcohol testing in compliance with Federal and State regulations for alcohol and controlled substance testing. Employees in positions holding responsibility for the safety and welfare of others will also be classified as safety sensitive.

El Rio Health is a Non-profit Federally Qualified Health Center (FQHC) and abides by all applicable federal Drug-Free Workplace standards