Registered Nurse Care Coordinator

Pillar Health is looking for experienced Registered Nurse Care Coordinators.

$5,000 hiring bonus - See below for details.

POSITION SUMMARY

The Registered Nurse Care Coordinator (RNCC) has a vital role within the KCHC/Pillar Health integrated care model. As a key partner to an assigned care provider(s) they support management of a patient panel using proactive and planned care goals while also coordinating the care team necessary to achieve them. The RNCC participates in the delivery of evidence-based care to an assigned patient population utilizing defined care standards, identifying care gaps, ensuring efficient access to care, care planning, and facilitating seamless care transitions and care continuity. The RNCC also participates in the analysis of outcomes, identification of opportunities for improvement, and implementation of changes to optimize outcomes for individual patients and the overall population. The position of the RNCC in the care model places the role in a unique position to facilitate an inter-professional team of clinicians in a wraparound care coordination model that will identify and address patient emergent, chronic, preventative care and social needs placing place patients in the best position for optimal health outcomes.

ESSENTIAL FUNCTIONS

The list of duties and responsibilities is not all inclusive and may be expanded to include other duties and responsibilities, as management may deem necessary from time to time.

Coordination and Management of the Patient Panel

· Reviews and assesses patient registration data, including outpatient or inpatient treatments, emergency room visits, medications, chart reviews, to assist in the monitoring and facilitation of adherence to prescribed care plans.

· Using the Electronic Health Record (EHR) and other electronic resources to identify patient care gaps and coordinate activities with the provider and care team to close those gaps.

· Utilizes organization defined risk stratification tools, EHR, and other electronic resources to risk stratify the assigned patient panel and track indicators of the panel.

· Chronic Care Management of medium, rising risk and high-risk patients

· Draw conclusions from available data to develop an overall strategy for the assigned patient panel as a whole, and individual patients in the different risk groups.

· Routinely evaluates social needs that can negatively impact health outcomes. Connects patients to available resources to meet those needs.

· Initiates or contributes to the development and implementation of individualized, comprehensive care plans including medical and social needs.

· Accesses internal and external resources to support development and implementation of the individualized and patient centered care plan.

• Facilitates patient understanding of the practitioner’s treatment plan, including but not limited to, prescriptions, refills, medical supplies, referrals, patient education, and when to seek care.

· Assists clinic and providers to meet efficiency, patient throughput, and productivity targets by serving as the clinical lead in a team-based approach to patient care.

· Uses reporting tools in the EHR and other electronic resources to monitor quality metrics and develop a plan with the provider and care team to implement improvements.

· Direct or telehealth patient education/coaching to improve health outcomes and achieve individualized patient goals.

· Coordinates internal and external Transitions of Care.

Coordination and Leadership of the Care Team

• Demonstrates leadership within delegation of duties and supervision to ancillary staff.
• Directs medical support and ancillary staff to ensure efficient patient throughput and an on-time patient schedule.
• Participates in onboarding, competency validation, and evaluation of medical support and ancillary staff.

Professional Practice Development

· Participation in practice committees and taskforces to ensure the implementation of standardized, evidence-based practice tools and educational materials to ensure consistency across the practice.

• Maintains patient confidentiality at all times and follows all HIPAA guidelines and regulations.
• Participates in scheduled Quality Indicators (QI) Committee meetings, including QI activities relative to grant related requirements.
• Communicates the clinic’s results on QI indicators to clinic staff & participates in action plan development.
• Solicits feedback from clinical team including suggestions for action plans, barriers, etc. and relays them to QI Committee.
• Other duties as assigned.

Effective Teamwork and Communication

· Actively participates in daily huddles to plan activities and resources for the day

· Participates in pre-visit planning activities with assigned provider, PCP, and other care team members.

· Communicates anticipated bottlenecks and delays in the daily schedule; works with team to adapt to get back on track.

POSITION REQUIREMENTS

Education and/or Experience

· Graduate of an accredited university or college of nursing. Bachelor’s degree preferred.

· Minimum of 2 years’ experience in a professional nurse role in an acute care or home care setting or experience in managing populations and patient care panels in an ambulatory or care management role.

· Experience with Electronic Health Record preferred.

License/Certification

· Licensed as a Registered Nurse in the State of Wisconsin.

· Current CPR Certification.

Physical/Environmental

· Intermittent physical activity including standing, walking, bending, reaching, and prolonged periods of sitting.

· Required to constantly operate computer, phone, and other clinical tools and/or equipment.

· Must be able to push, pull, or carry 25 lbs.

Knowledge, Skills, & Abilities

• Knowledge, skill, and application of electronic medical record required.

• Demonstrate a high degree of professionalism and service excellence.

• Ability to make knowledgeable clinical assessments and judgments.

• Excellent verbal and written skills required.

• Experience in developing care plans required.

• Ability and experience in monitoring nursing practice trends and making changes in clinical practice preferred.

• Must possess critical thinking skills, initiative, the ability to work independently and the ability to prioritize tasks.

• Ability to maintain confidentiality of medical records.

• Ability to prioritize tasks and to work in a changing/dynamic work environment.

• Knowledge of infection control.

WORK SCHEDULE

Open availability to work a minimum of 40 hours during clinic operating hours, Monday – Thursday, 7am – 7pm, Friday, 7am – 5pm and rotating Saturdays 7am – 3pm.

WHAT WE OFFER

As a full-time employee, you will receive an impressive portfolio of benefits designed to help you maintain a comfortable lifestyle for you and your qualifying dependents, including Major Medical, Dental, Vision, Flexible Spending Account, Short-term Disability, Long-term Disability, Life Insurance, Employee Assistant Program, 403(b) Paid Time Off, including Holidays. Loan re-payment eligibility through the National Health Service Corp (NHSC). Malpractice coverage through FTCA (Federal Tort Claims Act). Reimbursement for state license as required.

Pay to commensurate with experience.

$5,000 Hiring Bonus*

*Full-time Registered Nurse Care Coordinators hired between January 1, 2024, and March 31, 2024,will be eligible to receive a hiring bonus paid in 2 equal installments, paid after completion of 6 months and 12 months of service. Employee must be actively employed to receive payout. Internal candidates are not eligible.

Learn more about us at www.pillarhealthcare.org.

Kenosha Community Health Center and Pillar Health, a Division of Kenosha Community Health Center, are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability or veteran status.