• The RN Care Coordinator will provide personalized management for patients across the continuum of care as part of St. Joseph Health Partners Clinical Integration Initiatives. The Care Coordinator will navigate patients through the healthcare delivery system (inpatient, outpatient, ambulatory settings) for patients actively needing/ seeking care and will also engage patients who have been identified as needing interventions but not yet actively seeking assistance from their provider.

ACCOUNTABILITIES

• ESSENTIAL
  • Engage patients at the point of care (Inpatient and clinic settings) and establish a relationship/case plan that continues outside of the point of care with the primary goal of improving patient health as the patient and their physician define health.
  • Set clear expectations for patient responsibilities, support patient self-management in recovery, and establish feedback loops between patients and providers to identify complications early on.

• Proactively identify solutions to promote low acuity utilization before complications become high priority.
• Leverage data to identify changes in the health status of well-managed patients.
• Identify and implement case plans that are patient centric. Communicate with patients using the patients preferred method of communication.
• Understand value-based reimbursement models and the great impact they have on St. Joseph Health Partners.
• Follow evidence-based care pathways, coordinating care across multiple provider sites, and ensure patients follow recommended recovery care plans.
• Encourage informed patients to select appropriate treatment options and engage in self- management.
• Collaborate with both St. Joseph's providers and staff within their offices/clinics and also with healthcare providers in the community not affiliated with St. Joseph. Focus on cultivating collaborative working relationships with all community providers who interact with our patients with the goal of providing patient centric care.
• Performs other duties as assigned to meet the organization`s needs.
• Work with CI Executive Director and CI Outcomes Management to identify best practices for care coordination.
• Participate in workflow committees to develop best practices.

QUALIFICATIONS

• Education
• Required: Associates Degree RN
  Preferred: Bachelors Science in Nursing, BSN
• Experience
• Required: 5-7 years nursing experience
  Preferred: 5-7 years (Case Management, Utilization Management, ER, ICU, Home Health, or Hospice)
• Skills
• Required: Computer skills to include navigating complex reporting software and Microsoft Office.
  Ability to articulate care plan and patient needs to providers. Ability to identify patient self-directed care plans.
• Licensure/Certifications
• Required: RN from Texas Board of Nursing
  Preferred: CCM