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RN Care Coordinator - FT Days - GROVE Family Practice

Company: Integris Health
Location: Fayetteville
Posted on: October 7, 2021

Job Description:

RN Care Coordinator - Full Time Days - Grove Family Practice, Grove, OK

Job Code: 1335

Position Summary:

Through collaborative practice, the RN Care Coordinator will facilitate communication and care coordination activities along the care continuum recognizing the patient's right to self-determination, the significance of the social determinants of health and care complexities. In a targeted patient population, the RN Care Coordinator assist patients to achieve optimal health, access to services, education, and appropriate utilization of resources

INTEGRIS is an Equal Opportunity/Affirmative Action Employer. All applicants will receive consideration regardless of membership in any protected status as defined by applicable state or federal law, including protected veteran or disability status.

Essential Functions:

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


Reports to assigned Director or Manager.

Required Physical Demands (Subject to Reasonable Accommodation):

Keyboarding/Dexterity: Frequently; activity exists from 1/3 to 2/3 of the time
Standing/Walking: Occasionally; activity exists up to 1/3 of the time
Strength (Lift/Carry/Push/Pull): Sedentary (exerting up to 10 pounds of force occasionally)
Talking (Must be able to effectively communicate verbally): Yes
Seeing: Yes
Hearing: Yes
Color Acuity (Must be able to distinguish and identify colors): No

This position may have additional or varied physical demand and/or respiratory fit test requirements. Please consult the Physical Demands Project SharePoint site or contact Risk Management/Employee Health for additional information.

Environmental Conditions:

Normal office environment. When working in clinical areas, potential for exposure to infections and communicable diseases, blood and body fluids, electrical equipment, chemicals. Must follow standard precautions.

All applicants will receive consideration regardless of membership in any protected status as defined by applicable state or federal law, including protected veteran or disability status.

• Current licensure as a Registered Nurse (RN) in the State of Oklahoma or current multistate license from a Nurse Licensure Compact (eNLC) member state
• Bachelors degree in Nursing preferred
• Minimum of 3 years recent clinical experience in a variety of clinical settings
• Must obtain BLS within 90 days of hire and renew according to guidelines
• Care Management or Care Coordination experience preferred
• Excellent interpersonal communication and collaboration skills.
• Computer experience required. Windows and Excel preferred.
• This job requires the incumbents to operate a INTEGRIS-owned vehicle OR personal vehicle (non INTEGRIS-owned) and therefore must have a current Oklahoma State Drivers License as well as a driving record which is acceptable to our insurance carrier

Keywords: Integris Health, Fayetteville , RN Care Coordinator - FT Days - GROVE Family Practice, Other , Fayetteville, Arkansas

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