Nurse Care Coordinator - RN

Our client is seeking an experienced Nurse Care Coordinator, RN, with a passion for helping individuals grow in health literacy and self-management across the lifespan.  This role will assist individuals with mental health and substance use diagnoses better understand and manage their physical health conditions while learning to advocate for themselves within a complex healthcare system.

Job Duties

• Work closely with interdisciplinary care team manage care for high-risk, complex patient cases, including referral management, care planning, post-discharge planning and coordinating community-based and transitional care.
• Conduct individualized clinical evaluations of patient’s health needs; promote patient’s health and ensure that all goals are included in person-centered care management plans.
• Identify and manage other patient needs by making referrals to the appropriate personnel; validating the need was addressed.
• Identify patient educational, social and financial needs, referring to appropriate personnel.
• Curate/approve (in collaboration with program supervisor) educational materials for use with target populations served in this program with consideration of differences in cultural, generational and literacy needs across communities served.
• Provide health education to patients about preventing and managing chronic conditions using evidence-based sources.
• Develop personalized action plans, provide education, and issue referrals for care management programs; monitor patients’ progress in meeting established goals and modify care plans accordingly.
• Develop a cohesive and team-oriented relationship with physicians, nurses and other healthcare professionals.
• Evaluate and report on patient health outcomes and work in partnership with interdisciplinary healthcare team to facilitate the best in patient care.
• Direct discharge planning process in support of treatment adherence and medication compliance; assist with transitions for patients discharged from an in-patient hospital to a skilled nursing facility.
• Participate in the agency’s Quality Improvement (PQI) activities as assigned.
• Guide, intervene and advocate on behalf of patients, their caregivers and/or families in regard to navigating and comprehending the healthcare system; coordinate resources in the community to ease transition.
• Advocate on behalf of patients and caregivers for identification and access to services. 
• Advocate for the protection of the patient’s health, safety and rights.  Ensure patient choice and consistently support a patient centered environment.
• Perform other job-related duties as assigned.

Required Skills/Abilities

• Excellent interpersonal, negotiation, and conflict resolution skills.
• Excellent organizational skills and attention to detail.
• Excellent time management skills with a proven ability to meet deadlines.
• Strong analytical and problem-solving skills.
• Ability to prioritize tasks and to delegate them when appropriate.
• Ability to act with integrity, professionalism, and confidentiality.
• Proficient with Microsoft Office Suite or related software.
• Regular and predictable attendance, and promptness for work.

Education and Experience

• An active, unrestricted RN license with successful completion of a state-approved nursing program.
• Minimum of two years clinical experience.
• Strong knowledge of clinical assessment skills and experience with chronic disease management.
• Clinical experience in case management preferred.