Registered Nurse Case Coordination Family Medicine -- Family Medicine Center -- Heart & Vascular Cen

Job Summary

The RN Case Coordinator focuses on high-risk and medically complex patients by coordinating services across the healthcare continuum, addressing barriers to care, and supporting chronic disease management.

Responsibilities

• • Collaborate with physicians, resident physicians, advanced practice providers, nursing staff, behavioral health, pharmacies, community agencies, and other healthcare professionals to improve patient outcomes, promote continuity of care, and enhance the patient experience.

  • Assess patients' medical, psychosocial, functional, financial, and environmental needs that may impact health outcomes.
  • Develop, implement, monitor, and revise individualized care plans in collaboration with providers, patients, caregivers, and the interdisciplinary healthcare team.
  • Coordinate services across the continuum of care including specialty providers, hospitals, skilled nursing facilities, home health agencies, hospice, behavioral health, pharmacies, and community resources.
  • Advocate for patients by identifying and addressing barriers to care, including transportation, medication affordability, social determinants of health, and access to services.
• • Coordinate care for patients with chronic and complex conditions including, but not limited to, diabetes, hypertension, COPD, heart failure, asthma, obesity, and multiple chronic conditions.
  • Reinforce evidence-based treatment plans and patient self-management strategies.
  • Monitor patient progress toward established clinical goals and collaborate with providers regarding necessary interventions.
• • Coordinate post-hospital and emergency department follow-up care.
  • Complete timely outreach following hospital discharge in accordance with organizational and regulatory requirements.
  • Perform medication reconciliation and identify discrepancies requiring provider intervention.
  • Facilitate timely follow-up appointments, diagnostic testing, specialty referrals, and patient education to reduce avoidable readmissions.
• • Utilize electronic health record registries and reporting tools to identify care gaps and high-risk patient populations.
  • Conduct patient outreach related to preventive services, chronic disease management, immunizations, screenings, and quality initiatives.
  • Support organizational quality metrics, value-based reimbursement programs, and Patient-Centered Medical Home (PCMH) standards.
  • Participate in quality improvement initiatives designed to improve patient outcomes, access, patient satisfaction, and operational efficiency.
• • Provide individualized education regarding disease processes, medications, treatment plans, lifestyle modifications, and preventive care.
  • Promote patient engagement through motivational interviewing and shared decision-making.
  • Assist patients and caregivers in navigating the healthcare system and understanding available resources.
• • Collaborate with physicians, resident physicians, advanced practice providers, nursing staff, behavioral health, pharmacists, social workers, and community partners to coordinate comprehensive patient care.
  • Participate in interdisciplinary meetings, case reviews, and quality improvement activities.
  • Serve as a clinical resource regarding ambulatory care coordination and care management processes.
• • Document assessments, care plans, interventions, patient education, and communications accurately within the electronic medical record.
  • Maintain compliance with organizational policies, accreditation standards, regulatory requirements, and applicable payer guidelines.
  
  

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities
(Essential duties common to all positions)

1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.

Education

• Associate's Degree (Required) Preferred • Bachelor of Science in Nursing (BSN). • Certification in Case Management (CCM), Ambulatory Care Nursing (RN-BC), Care Coordination, or related specialty Experience Required • Minimum of one (1) year of clinical nursing experience. • Experience providing direct patient care in an ambulatory, primary care, medical-surgical, emergency, or community health setting. Does not have to be RN experience. • Experience utilizing an electronic health record. Preferred • Experience in ambulatory care, primary care, family medicine, internal medicine, or community health. • Experience with care coordination, chronic disease management, transitional care management, or population health. • Experience working within a Patient-Centered Medical Home (PCMH) or value-based care environment. • Experience collaborating within an interdisciplinary healthcare team.

Credentials

• Registered Nurse (Required)

Work Schedule: Days

Status: Full Time Regular 1.0

Location: Heart & Vascular Center

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Lauren R. Lane lauren.lane@vandaliahealth.org