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- Reduce unnecessary hospitalizations and re-hospitalizations by working with patients who were discharged from various healthcare facilities. Work with the primary care team to ensure follow-up visits are scheduled within 48 hours of facility discharge.
- Use Motivational Interviewing and coaching strategies to help patients identify and meet their healthcare goals.
- Develop individualized care plans to help patients track and meet their goals.
- Provide care coordination strategies via telephonic support and/or face-to-face to engage and educate patients.
- Develop and promote constructive relationships with inpatient, outpatient and community personnel to meet patient needs and goals.
- Guide process and performance improvement initiatives in the primary care setting to meet strategic goals.
- Engage with home care agencies, specialists, and any other integral providers or resources in case management activities.
- Prioritize high risk patient needs with physicians, office staff, and the health care team.
- Leverage clinical informatics to identify high risk, high need, and potentially high cost patients of the medical home to manage their care.
- Utilize electronic medical record (EMR) and chronic disease registry reporting to prioritize patient outreach.
- Coordinate with Case Management and Disease Management staff when applicable
- RN licensure required. BSN preferred.
- Certified Case Management (CCM) preferred
- Five to eight years of direct patient care experience required
- Must have experience with Microsoft Office (Word, Excel, PowerPoint).
- Must possess the ability to quickly learn new IT systems and software.
- Must be able to adjust and prioritize tasks in a dynamic environment.
- Experience with an EMR strongly preferred
- Experience analyzing, sorting and drawing conclusions from data strongly preferred.
rn care coordinator - Flemington, NJ , USA, United States - Hunterdon Health
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Description
RN Care CoordinatorThis innovative position places the registered nurse (RN) in a Care Coordinator role partnering with primary care providers. The majority of our primary care practices are certified Patient-Centered Medical Homes (PCMH).
The Medical Home Care Coordinator is a vital part of the multidisciplinary healthcare team which strives to coordinate care and optimize outcomes for patients and our healthcare system.
Care Transition Coaching and CoordinationEducation/Experience: