RN Care Coordinator – FT Days – Family Care Surrey Hills – Integris Health – Yukon, OK

The RN Care Coordinator responsibilities include, but are not limited to, the following:

• Assess patients for clinical, psychosocial, financial and other factors that may affect the quality and health outcomes.

• Evaluates the potential impact of social determinants of health that may elevate the patient’s risk in achieving optimal health outcomes.

• Collaborates with the care team to provide high quality, cost-effective, patient centered care.

• Provide patient education.

• Collaborate with patients/families/caregivers in goal setting, evaluates the level of understanding and engagement with the progress toward goals, and incorporates findings into the plan of care.

• Arranges services among community agencies, provider, patient/family/caregivers and others involved in the plan of care.

• Utilizes shared decision making with the patient/families/caregivers, develops a plan that is clinically appropriate and focused on the patient’s care needs and goals for care and treatment plan that is consistent with patient choice and available resources.

• Identifies barriers to achieving recommended goals identified in the plan of care.

• Promote wellness and provide education regarding preventative care measures.

• Completed Transitional Care Management per departmental key process standard work.

• Identify root cause for readmission to include patient/ family/caregiver perspective and implement strategies to reduce future risk.

• Convey all necessary information for continuity of care and patient safety, verify receipt and provide a venue for additional questions and/or

information requests/needs.

• Identify available community resources/potential partners and advocate for resolution of gaps in the available resources and processes.

• Support a mechanism to ensure a method of contacting the patient/family/caregiver within a timeframe appropriate to the site of care in order to validate the success of the transition and make their best effort to resolve any identified barriers to the plan of care.

• Documentation is included in the patient’s medical record and readily accessible to all other care team members.

• Knowledgeable of and ensure compliance with the federal, state, local organization and accreditation requirements that not only impact their scope of services but affect their ability to advocate for the patient. Case Management organizational structure, staffing, policies and procedures must meet the Centers for Medicare

& Medicaid Services (CMS) Conditions of Participation.

• All disciplines function within the scope of practice as defined by state licensing regulations.

• Case Management adheres to organizational policies, rules and regulations to promote prevention of fraud and abuse