Care Coordinator RN -Value-Based Services Organization, Seaford DE
Nemours Childrenâ€™s Health System
February 26, 2018
As one of the nation's leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children â“ even those who may never enter our doors â“ through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own.
The RN care coordinator will coordinate team-based care to provide health services and education to patients and families through effective partnerships with the PCP, community resources and medical professionals, the patient's medical home team, and the Nemours organization. Provides Care Coordination in the Primary Care setting by utilizing critical thinking skills and nursing expertise in order to optimize patient outcomes amongst designated populations within the practice. Works with patients and families to ensure both medical and psychosocial needs are met in order to promote health and well-being. Addresses gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk.
Essential Functions â“
Assist with the identification of patients in the practice with special health care needs; add them to the appropriate registry and use the registries to plan and monitor care. Monitors and audits patient registries/lists in accordance with NCQA Standards. Assists children with special health care needs and families in obtaining needed care to optimize quality of life and outcomes when possible.
Initiate family contacts and facilitate patient access to, and communication between, physicians and other team members.
Identify patient and family needs, gaps and/or barriers to care and patient/family strengths and assets. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse, complex medical patients, behavioral health issues, etc. facilitating appropriate connection to resources available to assist the patient and family to meet needs and overcome barriers to care.
Works cooperatively with families, patients, other members of the treatment team, social service agencies, community resources, and public agencies. Collaborates with the family and team to arrange for health care needs. Acts as a liaison for agencies and families with identified healthcare needs.
Utilizes the nursing process to coordinate the care of an identified population of pediatric patients throughout the healthcare continuum.
Coordination of services such as, transportation, referrals, and compliance. Assists families and patients through the healthcare system by acting as patient advocate and navigator connecting patients to relevant community resources with the goal of enhancing patient health and wellbeing.
Serve as point of contact, advocate and informational resource for family, patient, care team, school systems and their school nurses, community resources, and state agencies. Facilitates meetings/calls between patient /family, care team, payors, and outside agencies as needed.
Educates patient/family about a condition (existing or newly diagnosed) to assist them in appropriate self-management
Participates on a team for data collection, health outcomes reporting, clinical audits, and program evaluation related to the PCMH and Medical Neighborhood activities. Reports on Quality Improvement metrics/measures as needed for NCQA/PCMH/Nemours. Assists with the identification of areas for improvement within their practice.
Creates and promotes adherence to a care plan, developed in coordination with the patient/family, care management team and primary care provider.
Monitors specialty consults and follows up if patient/family did not follow through with the appointment or the consult report was not received by the PCP.
Contacts families with diagnostic testing results and advises next steps when needed.
Work with patient and family to facilitate access to the most appropriate care; reducing emergency room utilization and unplanned hospital admissions/readmissions.
Non-Essential Functions -
1. Facilitates the NCQA/PCMH process at the office working in close collaboration with the Medical Home liaison identified by NHPS. Be an active part of the medical home and facilitate the practice's Family Advisory Council.
2. Educate, counsel, and support patients regarding utilizing medical services appropriately; improve patient/family healthcare literacy- especially for high risk patients.
3. Works with chronic no-show patients to identify issues related to not keeping appointments.
4. Serve as medical home quality improvement team member; help to measure quality and to identify, test, refine, and suggest practice improvements.
5. Participates in Care Coordinator related meetings, training, and phone calls. Also participates in all NCQA/EPIC/EMR/Professional Development trainings as appropriate.
6) Assesses the effectiveness of patient programs/work flows regarding the high risk populations.
7) Evaluate outcomes of Care Coordination efforts by measuring intervention effectiveness and fostering a continuous improvement mentality.
Performance Skills -
Relevant experience in community based pediatrics, home health care, or primary care, particularlyin the care and service of high risk populations such as children/youth with special health care needs
Knowledge of community resources, culturally competent nursing care, and use of an EMR, spreadsheets, data collection.
Leadership, advocacy, education, and research skills.
Strong communication skills, with patients, families and across the health care team.
Proven problem solving skills to identify creative solutions to problems faced by patients and families
Experience and understanding of quality improvement initiatives
Ability to handle difficult situations involving patients, families, physicians or others in a professional manner.
Demonstrating excellent communication skills
Ability to work independently with a family centered approach which includes managing multiple assignments and simultaneous responsibilities to prioritize work and meet deadline
Must have or be eligible for DE nursing license
Pediatric experience required
CPR Certification with the American Heart Association
Bilingual Preferred- English and Creole
Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique âœBridge to a Healthy Futureâ pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.