Required Education and Experience: Registered Nurse license for the State of Florida and two years’ experience working in both inpatient and ambulatory care setting (physician office setting, hospital or Hospice). Proficiency with Excel is preferred. Excellent listening and interpersonal skills. Ability to maintain confidences. Must be flexible, resourceful, and able to problem solve. Must be able to handle multiple tasks simultaneously and set 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 to include: Transition of Care Management and Chronic disease management, active care planning and management of “high utilizers”, Medication Reconciliation and identifying barriers care to assist with successfully managing their disease state. The RN Care Coordinator is an essential member of the Quality Improvement team at Watson Clinic. He or she will work with both the care teams and the patients to support the goals of providing efficient, effective and quality care to our community.

Essential Functions and Responsibilities

• Identify patients for inclusion in program utilizing available metrics.
• Identifies and reduces barriers to care utilizing health plan services, community resources and organization as appropriate.
• Perform comprehensive patient assessments upon entry to service and periodically to include an assessment of patient and family support system and needs.
• Contact patients telephonically for care coordination and medication reconciliation post-discharge for hospital and skilled nursing discharges.
• Assists patient in gaining access to PCP and specialist appointments as needed.
• Follow established protocols to educate patients on disease management and promote patient self-management.
• Follow up on DME needs (met or unmet) and home health agency issues.
• Perform case reviews for ‘fragile few’ to present to treating physician.
• Develop and implement individualized patient care plan (that is goal driven) with a focus in disease management and patient empowerment.
• Assist patient and family with navigation of their health care plan.
• Monitor care plans and patient progress to goal achievement; revise plan as necessary providing education and support as appropriate.
• Assist patient and family to access available community resources as appropriate.
• Assists patient in gaining access to PCP and specialist appointments as needed.
• Maintain contact with patient and family through transitions of care while coordinating with other care team members.
• Participates as an active member of the patients care team collaborating with patient, family, providers, clinic staff, and other care partners.
• Document all encounters and patient related discussions, telephonic or in-person, in the EHR.
• Conduct home, hospital and clinic visits as appropriate, following established guidelines, policies and procedures.
• Process billing transactions as appropriate for Transitions of Care Management.
• Utilize Microsoft Product Suite, including but not limited to, insertion of data in an Excel spreadsheet from EHR. Use of Microsoft Word to create narrative reports of project(s) status.