Care Coordinator - Integrated Resources, Inc

Job Summary:
Primary Job Objective:
The Care Coordinator RN provides a deliberate patient and family centered partnership with the healthcare team that facilitates a seamless patient experience between the Inpatient and Outpatient settings. The Care Coordinator works to maximize the patient s health outcomes and the patient experience by identifying patient and family needs, completing pre-visit planning, supporting the clinic visit and providing closure to the clinic visits. Works to develop and support a coordinated plan of care between visits to promote a smooth transition for patients and family across the healthcare continuum that instills a sense of trust and patient advocacy.

Core Accountabilities:
-Coordinates care across the health care continuum within designated sub-specialty population(s).
-Serves as single point of contact by facilitating and overseeing transitions in care within and between care settings, providers, and services.
-Works to maintain primary care/referring physician involvement through ongoing communication.
-Leads a team approach to pre-visit planning Full use of EMR

-Coordinates and provides patient/family education that is shared and documented regarding specific diagnosis, treatments medication management, plan of care and transitions of care.
-Anticipates and documents patient needs for the next visit.
-Reconciles medications and medication refills and updates patients EMR accordingly
-May participate in Inpatient Care Conferences when indicated
-Completes pre-visit planning and post visit wrap-up and determines necessary follow-up appointments and/or treatments to optimize patient visit
. -Ensures that appropriate authorization for procedures/devices and medications have been obtained prior to services needed.
-Verifies results to ensure all necessary tests are completed and the results are available for the providers.
-Documents patient visit and completes billing information for facility fee
-Facilitates proactive disease management/preventative health care using evidenced based practice.

Performs other duties including:
-Performance Goals developed by manager and employee and reported in the employee s Performance Review as part of UMPhysicians Performance Management tools.
-Maintains core/universal competencies and completes any new required learnings.
-Demonstrates all critical competencies and new required learnings.

Required Skills & Experience:.
-3+ years of clinical nursing experience, preferably within specific patient population group.
-Proven ability to function at highest level within Product of practice.
-Patient education and pro-active disease management experience.
-Excellent assessment and care coordination skills.
-Experience with an EMR.
-Keyboarding/computer skills.
-Strong customer focus to accommodate patients.
-Proven ability to follow protocol specific care delivery expectations per sub specialty population

Preferred Skills & Experience:
-N/A
Schedule Notes:
40 hours per week through 12-2024; 30 hours per week from 1-1-25 through 1-31-2025; 20 hours per week through 2-7-25; subject to change based on clinic need.
Base Rate:
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