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RN Complex Care Coordinator - Care Management - Full Time
Hartland, WIPosted Today
Job Description
Job Summary
• Initiates, monitors and evaluates best practices for complex case management
• Collaborates with physicians, advanced practice providers, and ancillary health care team members to coordinate system and community resources to maximize advocacy for patient and family care in achieving the most effective outcomes
• Advocates for the patient by providing support and resources in order to reach optimal function and health, in an appropriate environment
• Develops a patient-centered plan of care to optimize wellness and quality of life, operating from an in depth understanding of their unique meaning of health, illness and disease
• Maintains a broad perspective of the patient’s journey across the Continuum of Care in order to assist with navigation and coordination of care
• Collaborates with physicians, advanced practice providers, and ancillary health care team members to coordinate system and community resources to maximize advocacy for patient and family care in achieving the most effective outcomes
• Advocates for the patient by providing support and resources in order to reach optimal function and health, in an appropriate environment
• Develops a patient-centered plan of care to optimize wellness and quality of life, operating from an in depth understanding of their unique meaning of health, illness and disease
• Maintains a broad perspective of the patient’s journey across the Continuum of Care in order to assist with navigation and coordination of care
Responsibilities
• Establishes trusting relationships with patients and families/caregivers
• Assists the patient in the examination, clarification and communication of their values
• Assesses patient activation: the knowledge, skills and confidence they have in managing their own health and health care
• Employs Motivational Interviewing to assist patients in identifying obstacles to self-management and develop patient-centered goals
• Promotes healing by helping the patient and family cope with the fears and concerns that accompany life and health changes
• Fosters a strong bond and facilitates partnership and communication between the patient and the primary care provider
• Creates an environment that supports life-long learning that empowers patients to self-manage
• Provides evidence-based patient education and assists in shared decision-making
• Applies a flexible and creative approach to problem solving
• Provides care coordination and collaboration during patient transitions across the Continuum of Care
• Identifies barriers to disease self-management and self-care, including Social Determinants of Health
• Facilitates patient access to PHC or community resources for disease-specific education, self-management and social support
• Functions independently and possesses the internal discipline/drive to guide care for patients with complex health needs
• Completes all EHR documentation accurately, timely and efficiently for regulatory compliance
• Demonstrates effective use of healthcare and information technology resources
• Attends appropriate educational opportunities and shares knowledge and experiences with others in formal and informal settings. Maximizes personal growth and develops an individual educational plan.
• Demonstrates a commitment to the values of the ProHealth Experience: Respect, Relationships, Communication, Collaboration and Excellence
• Assists the patient in the examination, clarification and communication of their values
• Assesses patient activation: the knowledge, skills and confidence they have in managing their own health and health care
• Employs Motivational Interviewing to assist patients in identifying obstacles to self-management and develop patient-centered goals
• Promotes healing by helping the patient and family cope with the fears and concerns that accompany life and health changes
• Fosters a strong bond and facilitates partnership and communication between the patient and the primary care provider
• Creates an environment that supports life-long learning that empowers patients to self-manage
• Provides evidence-based patient education and assists in shared decision-making
• Applies a flexible and creative approach to problem solving
• Provides care coordination and collaboration during patient transitions across the Continuum of Care
• Identifies barriers to disease self-management and self-care, including Social Determinants of Health
• Facilitates patient access to PHC or community resources for disease-specific education, self-management and social support
• Functions independently and possesses the internal discipline/drive to guide care for patients with complex health needs
• Completes all EHR documentation accurately, timely and efficiently for regulatory compliance
• Demonstrates effective use of healthcare and information technology resources
• Attends appropriate educational opportunities and shares knowledge and experiences with others in formal and informal settings. Maximizes personal growth and develops an individual educational plan.
• Demonstrates a commitment to the values of the ProHealth Experience: Respect, Relationships, Communication, Collaboration and Excellence