RN Care Coordinator

RN Care Coordinator – Job Description

Position Summary:

The Nurse Transitional Care Coordinator is responsible for facilitating patients’ care as they transition from hospital/post-acute care/rehabilitation to home. While conducting the patient’s transitional care outreach, the nurse will assess patient’s current medical status, identify patient’s needs, report or escalate any concerns to the patient’s primary care provider (PCP). In collaboration with the PCP, the nurse helps to implement the patient’s medical treatment plan and transitional care interventions. The nurse will also be responsible for educating patient/caregiver on: discharge teaching, acute and chronic medical conditions, medications, disease management and any other patient concerns. They will also prioritize medication adherence and strive to resolve any medication adherence barriers. The nurse is accountable for providing support to patients who are at risk for poor health outcomes and connecting them with appropriate resources and as needed, our internal Social Worker.

The Nurse is an integral component in our Accountable Care Organization’s (ACO) goals of reducing hospital readmissions, reducing avoidable emergency room visits, improving patient outcomes, providing high quality care, and supporting patients through various care management programs.

As a team member with Abacus Health, we serve through our mission and purpose of the Triple Aim + 2:

1. Improving the patient experience of care (quality and satisfaction)
2. Improving the health of populations
3. Reducing the per capita cost of health care

+2 Includes improving physician and employee satisfaction and Abacus income

Primary Responsibilities:

• Conducts comprehensive patient/caregiver outreach as part of transitional care management program in collaboration with patient’s PCP.
  • Performs thorough patient assessment and clear and concise documentation in the EHR
  • Communicates with patients/caregivers in a respectful and dignified manner
  • Completes accurate medication reconciliation
  • Identifies needs or barriers to care and compliance
  • Educates patients on acute and chronic medical conditions
  • Educates patients on reasons for hospitalization, ED visit, and reviews discharge summary from discharging facility
  • Serves as the patient’s advocate
• Accountable for timely patient outreach and EHR documentation
• Understands that our ACO serves to support our ACP providers
• Identifies opportunities for process improvement and actively participates in quality improvement projects as required
• Comprehends the importance of the ACO’s Quality Metrics
• Maintains active RN licensure and active Basic Life Support (CPR Certification)
• Completes yearly learning modules as assigned
• Performs all other job duties and functions as assigned