Position Overview: The Care Coordination Program at CAREMOUNT MEDICAL enables patients to be treated in an environment combining an expert medical team with individual attention and compassionate care. The Care Coordination Nurse empowers patients to actively participate in improving their own healthcare through personalized care that targets each patient’s specific healthcare issues and needs. The Care Coordination Nurse role is focused on reduction in Hospital readmission rates and use of the emergency department, based on determined avoidable causes. The Care Coordination Nurse performs essential, proactive, patient centered outreach to patients and their families post-discharge from various inpatient settings (i.e. hospital, SNF, Rehab, ER) to ensure patients and their families understand the discharge care plan and work to facilitate appropriate follow up, both long and short term, with the goal of reduction in health care cost and utilization. The Care Coordination Nurse is an integral part of CAREMOUNT MEDICAL care team and our approach to delivery of patient-centered, compassionate medical care, complementing the necessary professional services to patients.
Essential Duties and Responsibilities (including but not limited to the following):
- Integral member of the direct delivery care team, and serves as a gateway to information and support.
- Performs daily Transition Care Management (TCM/TOC) outreach calls to patients discharged from the ER setting. The patient communication goal is to review the recent ER Utilization and/or hospitalization, the discharge care plan and assess patient literacy of same.
- Utilizes tools and documents that support a guided care process, collaborating with patients/families/Physicians and other members of the care team toward an effective plan of care during the review of the hospitalization, including:
a) Assess patient and family’s unmet health and social needs
b) Provide effective communications to improve health literacy
c) Develop a care plan based on mutual goals with patient, family and provider’s emergency plan, medical summary and ongoing action plan, as appropriate. Monitor patient’s adherence to plan of care and progress toward goals in timely fashion, facilitate changes as needed.
d) Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists.
- Ensure effective tracking of test results, medication management and adherence to follow-up appointments.
- Facilitate communication between specialists and Primary Care Physician post-discharge for development of cohesive care plan, communicating action items to all responsible parties and following up to completion of same.
- Patient education and literacy assessment of appropriate ER utilization and navigation to disease management
- Attend and actively participate in care coordinator related training and meeting activities.
- Perform regular visits to provide patient and family support and education.
Qualifications and Education:
- Must be a registered nurse (RN) in New York State
- 3-5 years’ experience in clinical or community health settings, preferred
- Previous experience in caring for chronic disease patients, required
- Previous care Coordination, case management or Home Health experience, preferred
- Experience with navigation of local medical and social support systems,
- Previous experience with Electronic Medical Records and Microsoft Excel, preferred.
Knowledge, Skills and Abilities:
- Knowledge of community health services and willingness to develop and foster relationships with community resources of direct value to CareMount Medical patients and care team.
- Strong organizational skills and demonstrated the ability to maintain accurate notes and records.
- Strong interpersonal skills and an understanding and commitment to delivery of patient centered medical care with a team-based approach
- Ability to work independently, exercise creativity, is attentive to detail.
- Ability to manage multiple and simultaneous responsibilities and to priorities scheduling of work autonomously
All qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status. CareMount is an EO employer – M/F/Veteran/Disability