Care Coordinator RN - Temporary

Rochester Regional Health • Part-time • Massena, New York, United States • $65,000 - $90,100 / year • 7m ago

HOW WE CARE FOR YOU

At St. Lawrence Health, we are dedicated to getting health care right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for your career while caring for the community.

SUMMARY

The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s),clinic/hospital/specialty providers and staff, and community resources in a team approach. Facilitates “shared goal model” within and across settings to achieve coordinated high-quality care that is patient and family centered that address. Acts as a liaison between patients and the healthcare system. Ensures that patients receive the care they need and that they understand their medical condition, medications, and other instructions. Coordination of patient-care services to help reduce costs by reducing duplication of services.

STATUS: Temporary

LOCATION: Massena Hospital

DEPARTMENT: Behavioral Health

SCHEDULE: M-F, 8am-4pm

ATTRIBUTES

3-5 years’ experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.
Experience with Patient-Centered-Medical Home desirable.
Completion of an accredited Registered Nurse training program. BSN preferred.
Certification through the American Academy of Ambulatory Care Nursing in Care Coordination and Care Transitions required within 18 months of employment required.
Chronic Disease Self-Management Certification required within 12 months of employment.
Willingness to obtain ongoing and up to date population specific education

RESPONSIBILITIES

Care Coordination: Systematically identifies individual patients and plans, manages and coordinates their care, based on condition, needs and on evidence-based guidelines based on quality goals of organizations and population needs.
Provides assessment, care planning and coordination, and advocacy to patients and their families.
After assessing the health status of patients, develops, formulates, implements, and revises self-management care plans with a shared-goal model, incorporating patient specific education as appropriate for high risk patients and others, as defined by the practice.
Evaluation of patient responses to interventions, identifying and developing strategies to barriers in achieving positive clinical outcomes.
Coordinates care with community and regional ancillary health services for extended needs of patients and ensures that patient specific care plans are developed and documented by the practice clinical team.
Educates patient/family regarding relevant wellness issues, disease process, and treatment plan, if not bringing to the attention of the physician.
Educates patients with appropriate method suitable for individual learning abilities regarding diet, medication, or test needs, if not bringing to the attention of the physician.
Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
Promote timely access to appropriate care.
Increase utilization of preventative care.
Reduce emergency room utilization and hospital readmissions.
Increase comprehension through culturally and linguistically appropriate education.
Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).
Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
Tracks and reports on patient progress.
Manage referrals, when needed, to appropriate agencies required to assist the patient in achieving the goals and objectives defined in their Care Plan.
Defines and directs patients and/or families to appropriate resource utilization.
Increase patients’ ability for self-management and shared decision-making.
Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, reduce social barriers to care, and decrease health care costs.
Assist patients in problem solving potential issues related to the health care system, financial or social barriers (e.g. request interpreters as appropriate, transportation services, or prescription assistance.)
Assist with data collection and generation of patient registry reports.
Attends and participates in team/educational conferences as needed.
Care Delivery: Maintains safe and effective nursing care rendered directly or indirectly, adjusting nursing care processes as necessary to ensure optimal patient care.
Triage patient phone calls.
Provide medication reconciliation.
Pre-Visit planning prior to physicals of patients identified in registry.
Performs RN-Led Annual Wellness Visits
Make adjustments in patients' medications following physician directed guidelines to achieve therapeutic levels. Evaluates patient response to those interventions.
Placing orders for lab tests, immunizations or ancillary testing per protocol, under provider guidance.
Assist & manage follow-up care as requested by Primary Care physician.
Leads patient care team in daily and/or weekly huddle discussions to prepare for the day or week ahead.
Works closely with community resources to coordinate care needed by high risk patients, as defined by the practice.
Under direction of practitioners, communicate test results and care plans to patients/families.
Assists and completes various forms for the patient.
Responsible for coordinating and leading patient support groups and/or shared medical appointments.
Quality & Regulatory: Participates in Performance Improvement/Continuous Quality Improvement activities, as assigned.
Works with PPM management team to comply with all established standards and regulations per DNV standards and hospital compliance requirements.
Works with PPM management team to resolve clinical issues (processes, performance, etc.) to identify opportunities for improvement.
Adheres to CPH and PPM policies and procedures, protocols, guidelines, etc.
People: Serve as a mentor and a resource provider for clinic and hospital staff.
Provide education to patients and significant others, as well as staff.
Maintains a level of communication that exceeds the person’s expectations in every encounter.

EDUCATION:

LICENSES / CERTIFICATIONS:

PHYSICAL REQUIREMENTS:

M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

$65,000.00 - $90,100.00

CITY:

Massena

POSTAL CODE:

13662

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity/Affirmative Action Employer.

Minority/Female/Disability/Veterans by a prospective employee and/or employee’s Physician or delegate will be considered for accommodations.

Related Jobs

RN SUPERVISOR full time 10p-6a every other weekend starting salary $75000

Highland Nursing Home • Full-time • Massena, NY, US • 2w ago

RN Manager/Supervisor

Progressive skilled nursing facility seeks a full time RN supervisor to join its team. Will train right applicant. Excellent compensation available in a great working environment.

2w ago

VIEW JOB

RN Supervisor Weekend part time evenings and Overnights starting at $38 per hour

Highland Nursing Home • Part-time • Massena, NY, US • 2w ago

RN Manager/Supervisor

Progressive Skilled Nursing Facility is seeking experienced an RN Supervisor. The successful candidate must have experience as a Supervisor in a Skilled Nursing Facility. He/she must be a strong leader and motivator...

2w ago

VIEW JOB

Nursing Supervisor - Massena Hospital

Rochester Regional Health • Part-time • Massena, New York 13662, United States • $40.87 - $52.04 / hour • 2w ago

RN Manager/Supervisor

HOW WE CARE FOR YOU At St. Lawrence Health, we are dedicated to getting health care right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for yo...

2w ago

VIEW JOB

MDS Coordinator

Massena Rehabilitation and Nursing Center • Full-time • Massena, NY, US • 3w ago

RN MDS

We offer the following: Premium Compensation Great Benefits Package Fun, Family-Like Team, and Atmosphere! Work in a Beautifully Remodeled Office Professional Growth & Stability Innovative Training P...

3w ago

VIEW JOB

RN Part time or FT(12s) Over night supervisor 6p-6a

North Country Nursing and Rehabilitation Center • Part-time • Massena, NY, US • 3w ago

RN Manager/Supervisor

RN for Night Shift Supervisor. Will train right applicant. Good salary with differential Benefits. Good working environment. Come join our team.

3w ago

VIEW JOB

Registered Nurse - Massena Hospital

Rochester Regional Health • Part-time • Massena, New York, United States • $38.86 - $53.11 / hour • 3w ago

3w ago

VIEW JOB

Registered Nurse (RN)

Massena Rehabilitation and Nursing Center • Full-time • Massena, NY, US • $45 / hour • 3w ago

New Rate: ( Up To $45/hr) We offer the Following: Premium Compensation Great Benefits Package Fun, Family-Like Team, and Atmosphere! Work in a Beautifully Remodeled Office Professional Growth & Stabilit...

3w ago

VIEW JOB

RN Medication Nurse

Massena Rehabilitation and Nursing Center • Full-time • Massena, NY, US • 4w ago

New Rate: (Up To $45/hr) We offer the Following: Premium Compensation Great Benefits Package Fun, Family-Like Team, and Atmosphere! Work in a Beautifully Remodeled Office Professional Gr...

4w ago

VIEW JOB

RN Supervision

Massena Rehabilitation and Nursing Center • Full-time • Massena, NY, US • $45 / hour • 4w ago

New Higher Pay Rate (Up to $45/hr) Annual Salary Depending on License

4w ago

VIEW JOB

RN Positions Available! All Shifts! Starting at $38 per hour

Highland Nursing Home • Full-time • Massena, NY, US • 4w ago

RN Supervisors needed to manage various shifts for Highland Nursing and Rehabilitation Center About Us: Highland Nursing Home, a 140-bed Skilled Nursing Facility in Massena, NY, is looking for RN Shift Superviso...

4w ago

VIEW JOB