Outpatient Care Coordinator RN

The RN Care Coordinator will collaborate with providers, moderate-high risk patients and the primary care team to assess change readiness and develop a patient-centered care plan supported by management of chronic conditions measured by clinical indicators. RN Care Coordinators ensure all health care providers involved are up to date with case information re: their population and help guide patients through the health care system and cultivate relationships with health care providers by facilitating a shared goal model within and across settings to achieve coordinated high quality care that is patient centered.

• →Involve high risk individuals in activities to improve their health and partner with their care team to establish goals and action steps that focus on wellness and self-management of chronic conditions
• →Provide a coordinated strategic approach to detect early and manage effectively the patient with chronic disease.
• →Coach patients/families toward successful self-management of their chronic conditions
• →Create/update personalized care plans for patients. 
• →Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialist (e.g. Diabetes Educator). 
• →Cultivate and support primary care and sub-specialty co-management with communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals. 
• →Serve as the contact point, advocate, and informational resource for patient, family, care team, payers, and community resources. Ensure effective tracking of test results, medication management, and adherence to follow-up appointments. 
• →Linking patients to social services programs and entitlements such as transportation assistance and interpretation services.
• →Conducting regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.

• Current lndiana RN licensure required.
• Previous experience in caring for chronic disease patients. 
• BSN and 2+ years of experience preferred.
• CCM (certified case manager) preffered.
• Demonstrates evidence of essential leadership, communication, education, collaboration and counseling skills.  
• Outstanding communication skills, both written and verbal.
• Excellent organizational skills
• Ability to travel locally.
• Knowledge and sensitivity to communication strategies, accessibility and ability to identify appropriate communication strategies when required

The above statements are intended to describe the functions and related requirements of persons assigned to this job. They are not intended as an exhaustive list.