Description

Summary of Position: The Care Coordination RN (CCRN) works collaboratively with a multidisciplinary team to provide care coordination for patients who are experiencing or at risk of homelessness. The CCRN is a critical member of the patient care team who is responsible for developing and implementing a care coordination program throughout Circle the City’s (CTC) continuum of care including outpatient family health centers, medical respite centers and mobile unit-based outreach programs. The CCRN will focus on patient-centered health optimization and disease management for high risk and/or complex patients through risk stratification and evidence-based clinical guidelines. The CCRN will also focus on transitions of care, patient-centered health optimization and disease management for people experiencing homelessness that have recently visited the Emergency Department and had a hospital inpatient admission or have been discharged from Circle the City Medical Respite Program.

Essential Duties:

• Identifies patients experiencing or at risk for homelessness who meet criteria for care coordination (focusing on those who have multiple co-morbidities and/or are high utilizers of services) through risk stratification and provider referral.
• Assesses patient health learning levels to provide medical information and health education in culturally and linguistically appropriate communication techniques.
• Embraces and promotes a professional working environment based on understanding and respect for diversity and multi-culturalism in all its forms; demonstrates sensitivity, acknowledges varied beliefs, attitudes, behaviors, and customs, and encourages communication and appreciation of all forms of diversity.
• Provides care management, care coordination, and health coaching for the purpose of empowering patients to improve health.
• Develops culturally appropriate, comprehensive individualized patient-centered plans of care and implement targeted interventions based on risk stratification and evidence-based clinical guidelines.
• Conducts interviews to assist patients in identifying barriers to care and social determinants of health and appropriately refers patients to community resources as needed.
• Maintains an updated list of community resources.
• Continually monitors patient response to plan of care and need for revision as needed.
• Provides self-management support with a focus on empowering the patient to build capacity for self-care, providing resources, and education as necessary.
• Coordinates patient-centered care through ongoing collaboration with provider, patient, community, and other members of the healthcare team. Fosters a team approach and includes patients as active members of the team.
• Performs medication management with ongoing medication regimens and develops a patient directed self-management strategy for active participation.
• Assists with pre-visit planning for patients prior to appointments to close gaps in care, plan for preventative care, and addresses any outstanding referrals.
• Timely and accurately documents all patient interactions in the EHR, request medical records from outside organizations, and update charts with accurate data. Maintains required documentation within the Electronic Health Record (EHR) of all patient and healthcare team interactions, including documenting preventative care and services performed elsewhere.
• Conducts follow-up phone calls to patients to ensure they are meeting their goals and updates the status of managing their health issues. Oversees efforts and staff (i.e. medical assistants, licensed nurses, or other staff) responsible for coordination of care efforts.
• Uses data systems to monitor gaps in care.
• Recognizes data hygiene inconsistencies to improve population health reporting efforts
• Monitors EMR tasks and messages to assure timely management and response to patient and provider concerns and requests.
• Has an understanding and general knowledge of behavioral health diagnoses. Understands and utilizes the basics of motivational interviewing.
• Contributes to the integrated care team’s activities around process improvement, workflow design, and training.
• Participates in organizational Quality Assurance/Quality Improvement and Risk Management programs.
• Communicates with patients recently hospitalized or who have visited the Emergency Department via telephone in a timely manner, based upon provider recommendations and risk stratification.
• Gathers information regarding hospitalized patients from acute-care facility medical record systems while adhering to confidentiality guidelines and protocols
• Provides follow up with patient when the patient transitions from one setting to another. Completes timely follow up including medication reconciliation/adherence, specialist follow up, teaching, and problem-solving barriers.
• Contacts patients before hospital discharge to schedule an appointment with a CTC provider.
• Discusses medications (prescribed and over-the-counter) with patient in order to reconcile medications prior/post hospitalization.
• Reviews discharge planning to assure the patient receives prescribed durable medical equipment (DME), medications, and appropriate specialist follow up.
• Seeks collaboration with the medical provider and other interdisciplinary team members appropriately to optimize patient health.
• Provides data management, coordination, and patient outreach in collaboration with other population health strategies of the organization.
• Assists with pre-visit planning for patients prior to appointments to close gaps in care, plan for preventative care, and address any outstanding referrals.
• Conducts interviews to assist patients in identifying barriers to care and social determinants of health (SDOH) and appropriately refers patients to community resources as needed.
• Uses data systems to monitor gaps in care.
• Recognizes data hygiene inconsistencies to improve population health reporting efforts.
• Contributes to the integrated care team’s activities around process improvement, workflow design, and training.
• Maintains exceptional level of customer service; addresses and resolves complaints; serves as an example by providing excellent service to internal and external customers, employees and patients.
• Maintains an exceptional level of customer service; addresses and resolves complaints; serves as an example by providing excellent service to internal and external customers, employees, and patients.
• Coordinates and assists staff in providing excellent patient service.
• Maintains patient confidentiality by controlling the environment and information being disclosed to authorized individuals ensuring Health Insurance Portability and Accountability Act (HIPAA) and corporate compliance requirements at all times.

Qualifications

• Must be able to lift, carry, and push 20 pounds on a regular basis
• Must be able to lift and carry up to 50 pounds on an occasional basis
• Able to adapt to rapid, unpredictable workflow
• Able to focus on work at hand with attention to detail
• Ability to work with complex patients and those with mental illness

We are an equal-opportunity employer. All resumes will be reviewed for education and experience. Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status, or any other legally protected status.