RN Care Coordinator Ambulatory
RN Care Coordinator Ambulatory
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Salary Not Disclosed
1 Vacancy
Job Description
** Previous postacute (SNF Homecare Hospice) experience preferred.
- Using a variety of methods and tools identifies targeted highrisk population and chronically ill population within practice sites. Assesses the healthcare educational and psychosocial needs of the patient/family. Uses appropriate assessment tools such as depression screening functionality and health risk assessment.
- Collaborates with Primary Care Physician patient and members of the health care team to assess develop and implement an agreed upon plan of care. Participates in continuous quality improvement to enhance care management in the office setting. Monitors patient/family response to plan of care and revises the care plan as indicated. Provides selfmanagement support with a focus on empowering the patient/family to build capacity for self care. Ensure support for advanced directives and advanced care planning.
- Conducts comprehensive assessments to identify the members needs selfmanagement goals functional and/or cognitive impairment psychosocial issues environment and areas of risk or barriers that may impact the patients adherence to the care management plan.
- Using evidencebased guidelines and clinical tools identifies patients with chronic conditions and gaps in clinical care. Implements systems to ensure necessary care is completed and monitors individual patient progress and population health.
- Coordinates patient care by linking patients to resources. Provides follow up with patient/family when patient transitions from one setting to another. Completes post hospital discharge calls including medication reconciliation coordinates physician followup appointments symptoms assessment and patient education/ discharge instructions and problemsolves barriers to compliance.
- Maintains required documentation for all care management activities. Works with practice and Physician Organization/Accountable Care Organization leadership to continuously evaluate processes identify problems and propose/develop process improvement strategies to enhance the Patient Centered Medical Home delivery model and meet valuebased reimbursement payer program requirements.
- Reviews the current literature regarding effective engagement and communication strategies care management strategies and behavior change strategies and incorporates into clinical practice.
- Provides education on management of chronic conditions and enhances the members selfefficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change. Coordinate care transitions and monitoring of highrisk members following hospital and subacute discharges to ensure timely followup with primary care and prevent readmissions.
- Required Associates Degree or equivalent Graduate of an accredited school of nursing.
- Preferred Bachelors Degree of Science in Nursing.
- 2 years of relevant experience Minimum two years RN experience in a clinical care setting. Required
- 3 years of relevant experience Three to five years experience in care management home care and/or discharge planning. Preferred
- Experience in an ambulatory practice setting. Preferred
- Registered Nurse (RN) State of Michigan Upon Hire required
How Corewell Health cares for you
Comprehensive benefits package to meet your financial health and work/life balance goals. Learn more here.
Ondemand pay program powered by Payactiv
Discounts directory with deals on the things that matter to you like restaurants phone plans spas and more!
Optional identity theft protection home and auto insurance pet insurance
Traditional and Roth retirement options with service contribution and match savings
Eligibility for benefits is determined by employment type and status
Primary Location
SITE Beaumont Service Center 26901 Beaumont BlvdDepartment Name
Accountable Care OrganizationEmployment Type
Full timeShift
Day (United States of America)Weekly Scheduled Hours
40Hours of Work
8:00 a.m. to 4:30 p.m.Days Worked
Monday to FridayWeekend Frequency
Variable weekendsCURRENT COREWELL HEALTH TEAM MEMBERS Please apply through Find Jobs from your Workday team member account. This career site is for NonCorewell Health team members only.
Corewell Health is committed to providing a safe environment for our team members patients visitors and community. We require a drugfree workplace and require team members to comply with the MMR Varicella Tdap and Influenza vaccine requirement if in an onsite or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process to perform the essential functions of a job or to enjoy equal benefits and privileges of employment due to a disability pregnancy or sincerely held religious belief.
Corewell Health grants equal employment opportunity to all qualified persons without regard to race color national origin sex disability age religion genetic information marital status height weight gender pregnancy sexual orientation gender identity or expression veteran status or any other legally protected category.
An interconnected collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. As a health system we advocate for equity as we care for our patients our communities and each other. From workshops that develop cultural intelligence to our inclusion resource groups for people to find community and empowerment at work we are dedicated to ongoing resources that advance our values of diversity equity and inclusion in all that we do. We invite those that share in our commitment to join our team.
You may request assistance in completing the application process by calling 616.486.7447.
Required Experience:
IC
Employment Type
Full-Time
