- Identify patients eligible for the program using available metrics.
- Identify and address barriers to care by utilizing health plan services, community resources, and organizational support as appropriate.
- Conduct thorough patient assessments upon program entry and periodically, including evaluation of patient and family support systems and needs.
- Conduct telephonic follow-ups for care coordination and medication reconciliation post-hospital and skilled nursing discharges.
- Assist patients in scheduling appointments with primary care physicians and specialists as required.
- Educate patients on disease management following established protocols and encourage self-management.
- Address durable medical equipment needs and home health agency concerns.
- Review cases of 'fragile few' for presentation to treating physicians.
- Develop and execute personalized patient care plans focusing on disease management and patient empowerment.
- Aid patients and families in navigating their healthcare plans.
- Monitor care plans and patient progress towards goal achievement, adjusting plans when necessary while providing education and support when needed.
- Help patients and families access suitable community resources.
- Coordinate appointments with primary care physicians and specialists for patients.
- Maintain communication with patients and families during care transitions, collaborating with other care team members.
- Engage actively as part of the patient's care team, cooperating with patients, families, providers, clinic staff, and other care partners.
- Document all patient interactions, whether telephonic or in-person, in the EHR.
- Conduct home, hospital, and clinic visits following established guidelines, policies, and procedures.
- Handle billing transactions related to Transitions of Care Management appropriately.
- Utilize Microsoft Product Suite, including Excel for data entry from EHR and Word for creating project status reports.
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Care Coordination RN Senior - Tecumseh, Canada - Watson Clinic
Description
Required Education and Experience: Registered Nurse license for the State of Florida and minimum two years' experience in both inpatient and ambulatory care settings (such as physician offices, hospitals, or Hospice). Proficiency with Excel is a plus. Exceptional listening and interpersonal skills are a must. Ability to maintain confidentiality. Must possess flexibility, resourcefulness, and problem-solving skills. Capable of handling multiple tasks simultaneously and setting priorities.
Preferred Education and Experience: Bachelor's degree, Case Management Certification.
Summary/Objective:
Responsible for actively participating in the management of patients with complex needs, including Transition of Care Management and Chronic disease management, active care planning and management of high utilizers. Additionally, responsible for Medication Reconciliation and identifying barriers to care to help patients successfully manage their disease state. The RN Care Coordinator plays a crucial role within the Quality Improvement team at Watson Clinic, collaborating with care teams and patients to ensure efficient, effective, and quality care delivery to the community.
Essential Functions and Responsibilities:
