Chronic Care Coordination and Value Based Care Nurse
Chronic Care Coordination and Value Based Care Nurse
Posted on :
18-07-2025
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1 Vacancy
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Monthly Salary
Not Disclosed
Salary Not Disclosed
Vacancy
1 Vacancy
Posted on :
18-07-2025
Job Description
Chronic Care Coordination and Value Based Care Nurse
Summary:
This nurse position will work with patients family members and care team to create a customized patient centered care plan and coordination of care to improve patient outcomes reduced costs and enhance patient satisfaction for patients with multiple long-term health conditions. Upholds Mission Vision and Values of Open Door Health Services. This role will be Monday through Friday with potential to be 4 days a week and hybrid work after 90 days.
Responsibilities (How this position enhances our Mission Vision and Values)
Mission Improve the Quality of Life of Others:
This nurse position will work with patients family members and care team to create a customized patient centered care plan and coordination of care to improve patient outcomes reduced costs and enhance patient satisfaction for patients with multiple long-term health conditions. Upholds Mission Vision and Values of Open Door Health Services. This role will be Monday through Friday with potential to be 4 days a week and hybrid work after 90 days.
Responsibilities (How this position enhances our Mission Vision and Values)
Mission Improve the Quality of Life of Others:
- Assist patients by acting as patient advocate and healthcare coordinator.
- Works with healthcare team to create individualized patient centered care plans for patients with complex health issues and to periodically review and revise the patient centered care plan. Works collaboratively with other healthcare organizations and providers to build strategies that enhance patient outcomes and care coordination along the healthcare continuum.
- Nurse will focus on managing chronic diseases like diabetes heart disease obesity and asthma to list a few.
- Identify engage and enroll patients in chronic care management based on risk stratification standards.
Vision ODHS preferred partner in East Central Indiana for improving the well-being of individuals and the communities in which they live:
- Educates patients about their conditions treatment plans and self- management strategies.
- Empowers patients to actively participate in their care and improve their health outcomes.
- Proactively monitor patients conditions provide support and help patients make lifestyle changes to improve their health.
- Participates in Patient-Centered Medical Home and Quality Improvement
- Collaborates with other members of the care coordination team to improve patient outcomes and ensure quality metrics and payer incentives are met.
- Engages enrolls and maintains 90% of all eligible chronic care management patients.
Values Esteem the Team Maximize Potential Do the Right Thing Choose Compassion Encourage Uniqueness:
- Connect patients with social services and resources to address social determinants of health such as housing food and transportation.
- Initiatives through data collection health outcomes reporting and clinical audits.
- Coordinates the continuity of care with patients and families following hospital admission/discharge ER visits and transitions of care within identified time frames.
- Manages high risk patient care including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
- Be the primary contact for enrolled patients.
- Facilitates patient medication management by conducting medication reconciliations especially after a transition of care.
- Maintains flexibility in nursing assignments to include but not limited to follow-up chart audits and on floor nursing when needed.
- Provides ongoing teaching/counseling including but not limited to health status immunizations preventative health and health dangers screenings laboratory test personal hygiene diet birth control physical exams and available community resources.
- Participates in professional development activities and maintains professional affiliations.
- Implements the nursing process and communicates with the physician/mid-level practitioner regarding concerns and/or problems.
- Provides lab results to patients obtains and gives any prescription refill requests to providers and standing orders.
- Attends required meetings and in-services and participates on committees and quality improvement initiatives as requested.
- Completes and files paperwork needed for chronic care patients.
- Performs all other duties assigned.
- Supports ODHS outreach events.
- Supports other departments as needed & applicable.
- Other duties as assigned.
Education and Experience:
- Graduate of an accredited school of Registered Nursing.
- Two years of professional nursing experience in a healthcare setting.
- Prefer two years of professional nursing experience providing care coordination or case management to patients with complex needs.
- Indiana State Registered Nurse license CPR certification TB certification preferred required to be maintained through ODHS post hire.
About you:
- Knowledge of practices in accordance with nursing theory and all agency policies and procedures including privacy of protected health information.
- Skill in applying and modifying the principles methods and techniques of professional nursing to provide ongoing patient care.
- Knowledge of medical equipment and instruments to administer patient care.
- Knowledge of common safety hazards and precautions to establish a safe work environment.
- Skill in identifying problems and recommending solutions.
- Skill in preparing and maintaining department quality assurance and quality control standards.
- Skill in preparing and maintaining records charting and writing reports.
- Skill in establishing and maintaining effective working relationships with patients medical staff and the public.
- Ability to react calmly and effectively in emergency situations.
- Skill in written and oral communications pertaining to writing comprehensive care plans and measuring progress and outcomes.
- Maintains a cooperative relationship among health care teams by communicating information; responding to requests building rapport with patients and care team members; and participating in team problem solving methods.
- Ability to prioritize work assignments work independently and perform duties efficiently with minimal supervision.
- Understanding of individuals socio-economic status and lifestyle with respect for individual differences.
Physical and Environmental Requirements:
- Frequent exposure to communicable diseases toxic substances medicinal preparations and other conditions common to clinic environment. Tasks involve contact with blood or body substances.
- Requires standing walking or sitting for long periods of time. Occasional bending stretching or lifting up to 40 pounds.
- Requires the ability to work under stressful situations.
- Requires corrected vision and hearing to normal range or use of approved adaptive equipment
Employment Type
Full Time
Key Skills
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