Registered Nurse Chronic Heart Failure Care Coordinator

We're glad you are thinking about joining us

Grand Itasca is a great place for Registered Nurses! We're a non-profit organization with a clear vision of being the leader in transforming rural health care by achieving the highest levels of quality, access, and value. Our strength stems from teamwork and collaboration among a talented and diverse group of professionals. With over 700 employees in hundreds of different roles, Grand Itasca can offer a variety of career opportunities.

About the Position:

POSITION: Clinic RN Chronic Heart Failure (CHF) Care Coordinator

EMPLOYMENT TYPE: Part-time .8 - 1.0 FTE (64 - 80 hours per pay period)

WORK SCHEDULE: Days

DEPARTMENT: Clinic

Internal posting until 4/18/2024

What you'll do:

This role will be part of our Care Coordination program and has accountability for a panel of patients enrolled in the general program as well as patients enrolled in or referred to the Chronic Heart Failure (CHF) program. The RN Clinic/CHF Care Coordinator will work under the supervision of the Clinic Nursing Leadership team and focus on the social determinants of health, serve as an available resource advocating for patients, work collaboratively with the providers to manage population health, and provide education and support to the clinical teams. This role will also develop personalized treatment goals with the patient, support patient care and education, act as a liaison for patients to local resources, and be accessible to patients with urgent needs. Must stay current with CMS regulation regarding heart failure readmissions and excess post hospitalization acute care.

1. Utilizes the nursing process to provide holistic, compassionate, safe, high quality, and population-based care.
2. Carries out assigned nursing tasks and medical orders as delegate by providers to support patient care.
3. Coordinates services and support patients through care transitions such as home, hospital in-patient, nursing home, assisted living, and adult foster care for continuity of care and patient safety.
4. Completes Transitional Care Management (TCM) calls from hospital discharges and provide chronic care management services.
5. With direction and partnership from Cardiology providers, is responsible for the day-to-day Heart Failure program to follow all Heart Failure care delivered.
6. Partner in the development and implementation of a clinic and hospital-wide program to decrease Heart Failure (HF) readmissions and excess post hospital ER visits to maintain hospital compliance with current CMS regulation.
7. Helps maintain the program and identify opportunities for staff education and problem-solving with the heart failure team.
8. Builds a therapeutic relationship with patient and family and maximizes patient's participation and control in their own health care
9. Participates in care conferences with patients, families, and providers.
10. Provides evidence-based education to patients/families related to clinical care.
11. Participates in patient visits for complex medical issues and/or education.
12. Makes follow up patient phone calls to assess their status of reaching personalized goals.
13. Assists to coordinate follow-up appointments with primary or specialty care.
14. Facilitates patient continuity of care between clinic and hospital departments and programs.
15. Knows the key staff available to help patients with financial and emotional support; arranges for patients to meet with these resource people if needed.
16. Serves as an advocate and resource to patients in the clinic setting.
17. Develops and revises patient educational material.
18. Provides staff and community education as required.
19. Serve as a contact for patients, providers and other customers. Responds to incoming calls to the Care Coordination team.
20. Other duties as assigned.

Qualifications:

1. Currently registered with the Minnesota Board of Nursing.
2. Bachelor's degree preferred.
3. Current BLS certification or obtain within 2 months.
4. Demonstrates clinical competence in providing direct patient care, patient and family education, and assisting the provider in the coordination of patient care.
5. Demonstrated abilities to manage multiple priorities and organize workload; includes critical thinking, delegation skills, time management, and respectful communication.
6. Three to five years of experience working with health plans, clinic systems, or general health care environments with a focus of public health or care coordination experience preferred.
7. Certification in Diabetes Education preferred.
8. Motivational Interviewing experience preferred.
9. Skill in coordinating care needs.
10. Experience in program development.
11. Experience in Outpatient Care Coordination in Clinic practices preferred.

Let's Talk Benefits!

• Competitive pay
• Tuition reimbursement and scholarship/grant opportunities
• Health, dental, vision, & life insurance kick in on the first of the month after 30 days of employment
• Generous paid time off package to maintain a healthy home-work balance
• STDB (short term disability bank)
• 401K with employer contributions
• Experience Pay Given
• Employee Referral Program

About Grand Itasca:

Grand Itasca brings the benefits of a large and respected health system to our local community. We are a non-profit, state-of-the-art, integrated clinic and hospital that is proud to offer a range of high-quality providers, specialties and services to our community. Enjoy our patient-centered, comprehensive approach, close to home without venturing from the beauty of northern Minnesota.

EEO/AA Employer/Vet/Disabled All qualified applicants will receive consideration without regard to any lawfully protected status.