Complex Care Coordinator RN

Summary

Job Overview

The Complex Care Coordinator – RN manages a panel of patients identified as high-risk for meeting complex and/or chronic criteria to ensure comprehensive care is coordinated. The CCC, Nursing, promotes seamless care continuity, improved health outcomes, equitable access for the population of focus and comprehensive care considering physical, behavioral, and health-related social needs within time- limited designated timeframe. This position is responsible for managing patients with health care needs that create risk for poor health outcomes due to gaps in care, fragmented or complex care plans, delayed or duplicate treatment, and preventable/unnecessary ED or inpatient admissions. The coordinator ensures that the care provided is patient- and family-centered, evidence-based, fiscally responsible, holistic in nature, and leads to improved outcomes. The coordinator utilizes clinical expertise to drive care coordination efforts for their dynamic panel of patients, in partnership with the multi-disciplinary team.

ImPACT stands for "Improving Pediatric to Adult Care Transition," and supports and provides resources for adolescents and young adults, their families and primary and specialty care providers and teams to a successful adult care transition. ImPACT’s mission statement is reflective of our commitment to assure that we deliver high quality, evidence-based transition services. The team works with referring specialty and other services involved with the young persons' care to decrease fragmentation and streamline adult care transition. We support and advocate for all young people and their families during the transition process from pediatric to adult healthcare. We partner with young people and their families to integrate their long-term healthcare goals into the transition plan. We serve as coaches to patients and their families to provide health education and to enhance confidence and disease self-management. We foster communication between pediatric and adult care teams, patients and families to create individualized, uninterrupted continuum of care.

Department Name: Colorado Springs ImPACT

Job Status: full time, 40 hours per week, eligible for benefits

Shift: 0800-1730 Monday through Friday

This position is eligible for relocation assistance, if relocating from 100 miles or greater.

This position is made possible by and is funded through third party grants and/or restricted funding. The length of the assignment is dependent on the grant program and on funding availability. Based on current funding, the anticipated end date for this assignment is unknown. This position will be reviewed and may be extended in accordance with the grant. Should this position be discontinued and/or eliminated for any reason, it is not eligible for severance.

Essential Functions

An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the functions which the employee may be expected to perform.

• Promotes quality, equitable and individualized care by integrating considerations of social determinants of health with comprehensive mental and physical health care plan, ensuring that all patients have access to quality care, optimal health outcomes, and exceptional healthcare experience.
• Assess, develop, implement, and evaluate a patient’s individualized and time limited comprehensive care plan including physical, behavioral, and health related social needs to support patient health goals.
• Uses data to support the evaluation and improvement of population outcomes in collaboration with leadership.
• Leads and partners, where appropriate, with interdisciplinary team to identify resources to support the patient and family during care plan implementation and/or health decline to solve identified challenges.
• Identifies any barriers to the care plan and advocates for patient centered modifications as appropriate.
• Promotes autonomy of self-management of patient health care through supporting patient needs, education towards care plan and multidisciplinary collaboration.
• Educates the patient, family, guardian, and/or caregiver to support self-management and promotion of independence minimizing reliance on the health care system where appropriate. Identifies as the primary care coordinator and owns care plan efforts that support improved care coordination through sharing knowledge, acting as role models, and providing clinical expertise.
• Actively communicates with the patient, caregiver, agencies, and community service providers for the duration of the care plan.
• Engages with community resources including schools, pharmacies, specialty and primary care teams, and additional community-based partners.
• Proactively supports treatment adherence by using tools within electronic health record.
  
  

Minimum Qualifications

Education: Bachelor of Science in Nursing (BSN)

Experience: Three years nursing experience

Certification(s): BLS/CPR from the American Heart Association with at least 6 months left before expiration is required upon hire.

Licensure(s): Registered Nurse (RN) licensure in the state of Colorado is required.

Preferred Qualifications

• Experience in an ambulatory care setting
• Background in care coordination across multidisciplinary teams
• Demonstrated ability to work with patients and families managing complex, chronic conditions
• Understanding of managed care and value-based care models
• Proficiency in electronic health records (EHR) and care management systems
• Ability to track and use data to support care planning and quality improvement
  
  

Salary Information

Pay is dependent on applicant's relevant experience.

Hourly Range: $40.26 to $60.39

Benefits Information

Here, you matter. As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career.

As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April.

Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year.

EEO Statement

It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained.

Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.