RN Care Coordinator
The RN Care Coordinator is an integral member of the Center’s primary care practice teams and is responsible for providing care coordination and care management services to patients who are at risk for poor outcomes, health deterioration, co-morbidities and preventable hospitalizations. This includes coordinating and managing the care of chronically ill patients, and ensuring that patients receive optimal care in relation to acute illness management, chronic disease management, and preventive care across multiple health settings and with various multiple physicians/providers. This work is carried out in support of the mission and goals of Ryan Network.
Care Coordination, Care Management and Transitions of Care
- Coordinate patient care and care management, including care transitions, referrals, report management, and two-way communication between the Primary Care Physician (PCP), specialists, and other providers.
- Ensure transition of care for patients discharged from the hospital or ER within 24 – 48 hours to prevent readmission and related complications. Evaluate and provide appropriate follow-up care for recently discharged patients to prevent further disease exacerbation, complications, or additional ER or hospital utilization.
- Use data from the electronic health record to determine patients at highest risk for health deterioration, sentinel events, and/or poor outcomes
- Provide timely and ongoing communication with the PCP and practice team regarding their highest risk patients to maximize the management of patient needs and ensure that risk reduction activities are incorporated into the care plan.
Clinic Patient Care
- Assist with day-to-day patient care activities and tasks as needed. These will include but are not limited to: processing PCP forms such as prior authorization (PA), M11Q, home care orders, transportation and durable medical equipment (DME) device requests, patient education (focus on Diabetes and Hypertension teaching), pre-visit planning, post-visit planning pre-natal follow-up, medication administration, redirecting patients to appropriate services such as patient navigation, and attend daily huddles.
Collaboration and Committee Involvement
- Participate in Quality Improvement (QI) and Performance Improvement (PI) initiatives, including attendance at meetings, data input, and organization of project data and development of reports.
- Outreach in the community, participate in health fairs and occasional home visits.
- Other duties and/or projects as assigned.
Minimum Experience and Skills Required:
- Three years of experience in ambulatory setting (health center, emergency room or large practice).
- Computer literacy in MS Outlook, Word and Excel.
- Working experience with electronic medical records software.
- Demonstrated track record of organization, focus and ability to work in a fast-paced clinical setting.
Education, Licenses and/or Certifications Required:
- Associate Degree in Nursing.
- Valid Registered Nurse License in New York State.
- Valid BLS Certificate.
- Bachelor’s Degree in Science (BSN).
- eClinicalWorks experience.
- Bilingual: English/Spanish.
For consideration, please forward resume with salary requirements to firstname.lastname@example.org, and reference the job title in the subject line.
Equal Opportunity Employer
Ryan Network is an Equal Opportunity / Affirmative Action Employer and does not discriminate because of age, color, disability, ethnicity, marital or family status, national origin, race, religion, sex, sexual orientation, military veteran status, or any other characteristic protected by law. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce.