Care Coordinator 3 RN/Registered Nurse

Aunt Martha's Health and Wellness boldly commits to supporting the well-being of our communities, ensuring equity in access and delivering exceptional care inspired by a culture of innovation.
We are taking a responsible approach to creating environments that allow us to do what we do best-provide healthcare and wellness.
As a part of our commitment to health and safety, COVID-19 vaccines are required for all employees, as well as all newly hired employees.
We require documentation upon hire.

SUMMARY

Under the direct supervision of the Care Coordination Nurse Supervisor, the Care Coordinator 3 RN performs general functions including monitoring and coordination of the healthcare needs of patients to ensure appropriate delivery of healthcare services.
The Care Coordinator 3 RN ensures high and medium risk patients receive a comprehensive risk assessment, working care plan, and health education to include but not limited to appropriate ED utilization.
The Care Coordinator 3 RN is responsible to work with health center staff including primary care providers as well as clinic staff that provide care and services to Aunt Martha's patients.
The Care Coordinator 3 RN provides excellent quality care, positive customer service, the maintenance of an efficient and safe environment of care.
Demonstrates superior customer service skills and has the ability to function in a multi-tasking, multiple priorities environment, while maintaining accuracy and attention to detail.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Maintain patient confidentiality at all times per the policies and procedures.
Maintain ethical behavior at all time per the policies and procedures.
Responds to internal and external customer needs in a positive manner, utilizing principles of the AIDET model; exceeding their needs and expectations and providing the highest quality service to ensure the best possible outcomes.
Master the electronic health record system, Athena, to appropriately document patient data and information, in addition to managing databases with outcomes data.
Maintains accurate and timely documentation in the EMR
Collaborate with care coordination and clinic staff, other Aunt Martha's division programs and external agencies or organizations to ensure patient's medical and social needs are met.
Performs all required and appropriate assessments for care-managed population.
This includes physical and psychological assessments as appropriate.
The assessment includes a systematic and pertinent collection of data about the health status of the patient.
Completes all initial and ongoing assessments/documentation within indicated time frame as specified by program and/or supervisor.
Conducts review/update of established care plan for high risk patients within 30 days of prior care plan review/update.
Prioritize patients according to risk stratification, need and required follow up.
Formulates and implements a care management plan for high risk patients that addresses the patients identified needs by assessing the patient/family needs, issues, resources and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family.
Plans will contain specific mutual self-management SMART goals, objectives, and interventions.
Identifies and effectively utilizes community resources to meet the needs of patients/families.
Initiates and maintains communication and collaboration with physicians, social workers, care team leaders, staff nurses, other care giving disciplines, and patients/families to develop, implement, and evaluate a transition plan of care for each patient
Identify patients at risk of admission or emergency room utilization, outreach to and link them with appropriate resources to prevent any unnecessary care
When applicable, assist patient and hospital staff with transition planning at the time of admission to the hospital or SNF to appropriately decrease length of stay and ensure that the patient and family are prepared for the transition
When applicable, ensure that the hospital or SNF discharge summary is available to the primary care provider within 2 days of discharge to ensure a smooth transition, improve communication and coordination, and minimize the risk of readmissions.
Review discharge summary with patient/family.
When applicable, ensure patient follow-up appointment with their primary care provider within 7 days is scheduled prior to discharge, and act as a liaison between the hospital or SNF and the primary care provider.
Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence.
Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
Performs follow up calls for patients recently discharged from acute hospitalizations, and who are considered high risk for readmission.
Performs medication reconciliation for all care transitions.
Participates in regular team meetings and peer review activities.
Participates in the orientation of new personnel.
Precepts and mentors peers.
Promotes collaborative teamwork.
Abides by the organizations compliance program and requirements.
QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill, and/or ability required.

EDUCATION and/or EXPERIENCE B.S.
Degree in Nursing or A.A.
Degree with 2 years' experience working in the healthcare field preferred
Experience in working with Microsoft Office programs essential; adept at data entry
LPN/LVN license with 3 years experience in healthcare field
OTHER QUALIFICATIONS Current driver's license
Current auto insurance
Ability to work late evening hours, weekend hours, and scheduled holidays, as needed

Aunt Martha's is an equal opportunity employer.
All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.