RN Care Coordinator- Crittenden Primary Care

Job Type: Regular Scheduled Hours: 40 Job Summary: Reports to Manager of Care Coordination, works collaboratively with providers, (interdisciplinary staff) and clinical associates to support patients with chronic conditions and/or complex needs according to guidelines established by (care transition) the primary care and other clinical programs such as PQRS, PCMH, etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns. Job Description: Job Title: SEP - RN Care Coordinator (OCC) Location: Crittenden Primary Care DUTIES AND RESPONSIBILITES: Documents in chart appropriately utilizing care management documentation. Provides patient care through collaborating with patients, providing education and clear direction to the patient and address patient concerns regarding care. The RN engages in critical thinking to meet patient needs. Support Chronic Disease Management and Patient Care Needs: - Identify patients with chronic disease, rising risk concerns, social, financial, or educational needs for care management services. - Respond to provider referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or blood pressure, Mental Health Integration referral, complex needs) - Evaluate and collaborate with patients’ and families to determine readiness to change and resources for support. - Monitor compliance with plan of care and problem solve barriers to patient self-management. - Provide support for patient and family issues, resource needs, and answering general healthcare questions. - Do ADL assessment and home safety assessments based on patient interview. - Identify and place order for services such as HH when patient has identified need - Utilize teach back method for pts who have no medical necessity to justify home health. - Assess need and provide basic diabetic teaching (glucose meter testing, etc.) - Assess need and obtain required order for patient to receive disease management teaching or counseling (MD referral required for billing) - Document RN Care Coordinator interventions in Epic within care management documentation. - Refer non-nursing functions, such as assisting patients with completion of Medicaid, disability, pharmacy program or other eligibility applications, and scheduling appointments to designated resources in the region. - Coordinate with care managers in other settings as appropriate. - Carry out assessments and make decisions on his or her own before seeking the support of a supervisor. - Assist providers, patients, and families with Advance Care Planning - Explain results from screening based on protocol and guidelines. - The RN is expected to perform medication reconciliation for each patient on their panel. Provides ongoing management for chronic conditions, working with patients to meet healthcare goals per cadence expectations. Patient Education: - Provide education and pre-printed, SEP approved educational materials as needed, or at provider or patient request - Work collaboratively with patients to assess needs and develop a patient education plan of care. - Answer clinical questions related to patients’ chronic health conditions. - Provide group education for established patients. - Must understand professional boundaries and appropriately refer diagnostic questions to MD. - Refer patients appropriately when needs for mental health, pharmacy, social work, respiratory therapy etc. are identified. - Work telephonically with patients as needed. Ensures complete and accurate information in the Electronic Health Record. Coordinate referrals to community resources (e.g. home health, Durable Medical Equipment, support groups) - Forward written physician orders for treatment - Assess patient for additional needs, develop nursing plan of care and contact physician for order-dependent items. Coordinate scheduling of appointments when support is needed for a multitude of disciplines. Maintains adequate level of resources for care coordination. OSHA and HIPAA compliance. Assists with completion of patient requests in a timely manner. Timely and accurate complete charting of all patient information. Other duties and responsibilities as assigned are complete in a timely and accurate manner. Maintain good working relationships communications with all interdisciplinary team members, management, and utilization review staff for coordination of care and care transitions. Work with providers, interdisciplinary staff, and office staff to identify appropriate patient population for advance care planning. Work directly with patient to educate, provide resources, and manage their disease processes. Manage and perform home visits with patients as needed if a component of care management expectations. Attend meetings as required. In office support for nursing tasks such as: PPD, IRIS Exams, CGM starts, etc. Collaborative communication with office staff to be available for warm hand offs and immediate patient needs. Assessment of medication affordability and assisting patients with identified needs. REQUIRED SKILLS AND KNOWLEDGE: Ability to manage and prioritize multiple tasks. Knowledge of electronic Health Records – (EPIC) Knowledge of Excel, Word, Outlook and PowerPoint and the ability to learn other computer skills as needed. Good organizational skills. Work professionally with doctors, hospital administration and management, SEP associates and the public. Organized, neat and self-motivated. Warm personality with concern for others. Excellent verbal and written communication skills. Excellent interpersonal skills. Ability to affect change. Ability to perform critical analysis. Self-directed Work well telephonically as well as face to face. Can work autonomously. Be familiar with motivational interviewing with patients. Positive attitude Quest for learning and excellence. OTHER REQUIRED SKILLS AND KNOWLEDGE: Previous Quality Assurance experience preferred EDUCATION: -Degree in nursing (ADN or higher) -Current Driver’s License in good standing and reliable and insured transportation LICENSES AND CERTIFICATIONS: -Kentucky Registered Nurse (RN) Compact License (or any RN compact license) required. -Care Management Certification preferred. YEARS OF EXPERIENCE: -Minimum of 3 years nursing experience or current care management position held within SEP Clinical Transformation. -Demonstrated knowledge of anatomy and physiology, pharmacology, etc. -Ambulatory and/or care management experience. FLSA Status: Non-Exempt Right Career. Right Here. If you have a passion for taking care of the community and are interested in Healthcare, you will take pride in the level of care we provide at St. Elizabeth. We take care of patients and each other. St. Elizabeth Physicians is an equal opportunity employer and will not discriminate on the basis of race, color, sex, religion, national origin, ancestry, disability, age or any other characteristic that is protected by state or federal law.

RN

Director of Nursing

Full-time

4 months ago

Director of Nursing RN

Majestic Care of Middletown Middletown, OH

Director of Nursing (DNS) Registered Nurse Majestic Care of Middletown is looking for a Director of Nursing (DNS) to join our team's mission and believe in our core values! Our mission: Through the hearts of our Care Team Members, we provide excellent healthcare to those we serve. Our Core Values... L - Listening E - Empathy A - Accountability D - Decisiveness This is how we create a culture to LEAD with Love. Position Overview: The Director of Nursing Services (DNS) plans, coordinates, and provides total nursing care for residents and provides supervision and guidance to clinical care team members. Key Responsibilities: Assume responsibility of the community in the absence of the Executive Director. Implement policies/procedures with follow-up and supervision of care team members to ensure compliance; work closely with Medical Director, Health Department, CDC, etc. to ensure current standard practices are in place; recommend to regional office changes in policies/ procedures as needed. Assist in preparing budget for the department; administer approved budget. Direct and delegate management of professional and ancillary nursing care team members. Coordinate activities of various nursing units/wings promoting and maintaining harmonious relationships among nursing personnel and with medical staff, residents, community staff and the public; screen clients prior to admission to ensure the center can provide services. Analyze and evaluate nursing and related services rendered to improve quality of resident care and plan better utilization of care team member time and activities. Ensure positive outcomes are accomplished for residents; responsible to develop systems and work schedules that respect resident’s lifestyle and ensure the resident reaches the highest attainable level of functioning; make rounds at least daily; follow up daily on each shift to ensure changes in status are reported and recorded. Ensure a Continuous Quality Improvement Program is in place and that appropriate follow-up occurs. Ensure new care team members are effectively oriented; ensure an ongoing educational program is in place. Develop goals and objectives for the department; motivate and manage care team members to accomplish the same. Qualifications: Graduate of accredited school of nursing. Licensed as a RN in the state employed; license must be active, valid, and in good standing. Must hold an active CPR license or ability to obtain within the first 30-days of hire; CPR license must be kept active and current throughout employment. Valid CPR teaching certificate preferred, but not required. Three year of nursing experience, of which one year in a long-term care environment. Must have at least two years supervisory experience. Majestic Difference Benefits: Quarterly Pay Increase Daily Pay Company-Paid Life Insurance Telehealth Services 7 Company-Paid Holidays Care Team Member Relief Fund Join the Majestic Care team where compassion meets excellence! #HiMed

Director of Nursing RN

Majestic Care of Middletown Middletown, OH

Director of Nursing (DNS) Registered Nurse Majestic Care of Middletown is looking for a Director of Nursing (DNS) to join our team's mission and believe in our core values! Our mission: Through the hearts of our Care Team Members, we provide excellent healthcare to those we serve. Our Core Values... L - Listening E - Empathy A - Accountability D - Decisiveness This is how we create a culture to LEAD with Love. Position Overview: The Director of Nursing Services (DNS) plans, coordinates, and provides total nursing care for residents and provides supervision and guidance to clinical care team members. Key Responsibilities: Assume responsibility of the community in the absence of the Executive Director. Implement policies/procedures with follow-up and supervision of care team members to ensure compliance; work closely with Medical Director, Health Department, CDC, etc. to ensure current standard practices are in place; recommend to regional office changes in policies/ procedures as needed. Assist in preparing budget for the department; administer approved budget. Direct and delegate management of professional and ancillary nursing care team members. Coordinate activities of various nursing units/wings promoting and maintaining harmonious relationships among nursing personnel and with medical staff, residents, community staff and the public; screen clients prior to admission to ensure the center can provide services. Analyze and evaluate nursing and related services rendered to improve quality of resident care and plan better utilization of care team member time and activities. Ensure positive outcomes are accomplished for residents; responsible to develop systems and work schedules that respect resident’s lifestyle and ensure the resident reaches the highest attainable level of functioning; make rounds at least daily; follow up daily on each shift to ensure changes in status are reported and recorded. Ensure a Continuous Quality Improvement Program is in place and that appropriate follow-up occurs. Ensure new care team members are effectively oriented; ensure an ongoing educational program is in place. Develop goals and objectives for the department; motivate and manage care team members to accomplish the same. Qualifications: Graduate of accredited school of nursing. Licensed as a RN in the state employed; license must be active, valid, and in good standing. Must hold an active CPR license or ability to obtain within the first 30-days of hire; CPR license must be kept active and current throughout employment. Valid CPR teaching certificate preferred, but not required. Three year of nursing experience, of which one year in a long-term care environment. Must have at least two years supervisory experience. Majestic Difference Benefits: Quarterly Pay Increase Daily Pay Company-Paid Life Insurance Telehealth Services 7 Company-Paid Holidays Care Team Member Relief Fund Join the Majestic Care team where compassion meets excellence! #HiMed

Director of Nursing RN

Majestic Care of Middletown Middletown, OH

Director of Nursing (DNS) Registered Nurse Majestic Care of Middletown is looking for a Director of Nursing (DNS) to join our team's mission and believe in our core values! Our mission: Through the hearts of our Care Team Members, we provide excellent healthcare to those we serve. Our Core Values... L - Listening E - Empathy A - Accountability D - Decisiveness This is how we create a culture to LEAD with Love. Position Overview: The Director of Nursing Services (DNS) plans, coordinates, and provides total nursing care for residents and provides supervision and guidance to clinical care team members. Key Responsibilities: Assume responsibility of the community in the absence of the Executive Director. Implement policies/procedures with follow-up and supervision of care team members to ensure compliance; work closely with Medical Director, Health Department, CDC, etc. to ensure current standard practices are in place; recommend to regional office changes in policies/ procedures as needed. Assist in preparing budget for the department; administer approved budget. Direct and delegate management of professional and ancillary nursing care team members. Coordinate activities of various nursing units/wings promoting and maintaining harmonious relationships among nursing personnel and with medical staff, residents, community staff and the public; screen clients prior to admission to ensure the center can provide services. Analyze and evaluate nursing and related services rendered to improve quality of resident care and plan better utilization of care team member time and activities. Ensure positive outcomes are accomplished for residents; responsible to develop systems and work schedules that respect resident’s lifestyle and ensure the resident reaches the highest attainable level of functioning; make rounds at least daily; follow up daily on each shift to ensure changes in status are reported and recorded. Ensure a Continuous Quality Improvement Program is in place and that appropriate follow-up occurs. Ensure new care team members are effectively oriented; ensure an ongoing educational program is in place. Develop goals and objectives for the department; motivate and manage care team members to accomplish the same. Qualifications: Graduate of accredited school of nursing. Licensed as a RN in the state employed; license must be active, valid, and in good standing. Must hold an active CPR license or ability to obtain within the first 30-days of hire; CPR license must be kept active and current throughout employment. Valid CPR teaching certificate preferred, but not required. Three year of nursing experience, of which one year in a long-term care environment. Must have at least two years supervisory experience. Majestic Difference Benefits: Quarterly Pay Increase Daily Pay Company-Paid Life Insurance Telehealth Services 7 Company-Paid Holidays Care Team Member Relief Fund Join the Majestic Care team where compassion meets excellence! #HiMed

Weekend Supervisor, RN

Majestic Care of Middletown Middletown, OH

Weekend Supervisor Nurse, RN Majestic Care of Middletown is looking for a Weekend Supervisor, RN to join our team's mission and believe in our core values! Our mission: Through the hearts of our Care Team Members, we provide excellent healthcare to those we serve. Our Core Values... L - Listening E - Empathy A - Accountability D - Decisiveness This is how we create a culture to LEAD with Love. Position Overview: The Weekend Supervisor is responsible for directing the operation of a nursing unit in a long-term community. Key Responsibilities: Perform general management functions such as hiring, disciplining, and evaluating care team members. Plan and facilitate meetings and committees to address resident care issues/concerns for the unit. Manage area of responsibility with the goal of achieving and maintaining the highest quality of care possible. Participate in developing, implementing, and evaluating programs that promote the recruitment, retention, development, and continuing education of nursing staff members. Contact physicians as needed/necessary and ensure physician interventions are timely and appropriate. Review staffing patterns and census of nursing units and reassign personnel when necessary to ensure staffing meets resident needs and budgetary controls. Monitor the clinical operations of the unit and resident’s conditions and ensure that appropriate and quality care is administered. Obtain medications, supplies and medical records needed to provide safe, efficient, and therapeutic are to residents on a continuing basis. Assist in the orientation of new personnel, monitoring their skills and guides and observe care team members that may need assistance with procedures. Qualifications: Graduate of accredited school of nursing. Licensed as a RN in the state employed; license must be active, valid, and in good standing. Valid CPR teaching certificate preferred, but not required. Must hold an active CPR license or the ability to obtain within the first 30-days of employment. CPR license must be kept active and current throughout employment. Three years of nursing experience, of which one year in a long-term care environment. Majestic Difference Benefits: Quarterly Pay Increase Daily Pay Company-Paid Life Insurance Telehealth Services Double Pay on Holidays Care Team Member Relief Fund Join the Majestic Care team where compassion meets excellence! #HiMed

Local Med Surg (Medical Surgical) RN (Registered Nurse) in Cincinnati, OH - 1101975L

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