Rn - Care Coordinator

Department: 23007305 System CM AXIS Ucare
Shift: Day (United States of America)
Hours: 40
Contract: Non-Union
Weekend Rotation: None
Job Profile Summary: Establishes collaborative processes that promote quality and cost effective care that optimizes the physical and psychosocial health of participants across the continuum of care. Responsible for conducting comprehensive assessment and oversight and making decisions that impact health care outcomes, resource allocation and participant satisfaction. Independently coordinates complex panel of participants while ensuring an interdisciplinary approach with care team providers that results in an integrated person centered plan of care. This collaborative care plan is designed to advocate and assist participants in coping with complex health issues and enhance the person’s ability to function and access appropriate services. Provides clinical consultation as needed to medical providers, pharmacists, non clinical staff, clinical staff and other team members as appropriate.
Job Description:
Principle Responsibilities

• Conducts Comprehensive Assessment.
  • Gathers all relevant data and information by communicating with the participant, family, healthcare provider, other members of the healthcare delivery team and community support network including external healthcare providers and agencies.
  • Completes a medication review with attention to eliminating barriers to medication adherence.
  • Uses clinical expertise and established criteria to identify risk factors and determine recommendations to mitigate adverse health outcomes.
  • Evaluates data identifying strengths and barriers including social determinants impacting health and chronic or acute problems or conditions impacting function and quality of life.
• Develops Plan.
  • Develops a person centered care plan that focuses on enhancing strengths to support health and well being.
  • Builds trust with participant to encourage full engagement in care planning process and implementation.
  • Communicates care plan to participant, health care provider and community supports to ensure most effective implementation.
  • Supports planning across the continuum of care in collaboration with other health care providers, specialty and community providers to facilitate transitions of care.
  • Supports planning with community resources and external healthcare agencies to provide broadest available integrated network of support as needs indicate.
  • Maintains high level oversight of the integrated plan to assure goals are met and addressed.
• Facilitates Implementation of Plan.
  • Maintains contact with participant and relevant circle of support as required/needed to promote best health outcomes.
  • Works with participant, family and providers to resolve identified barriers.
  • Works with participant, family, healthcare providers and community supports to coordinate needed services.
  • Utilizes motivational interviewing skills to facilitate and engage participants towards behavioral changes through exploration and resolving ambivalence.
  • Facilitates communication between participant, family and all members of the health care team.
  • Facilitates referrals for participants as appropriate.
  • Administers health care benefits and coordinates care within the benefit set.
  • Identifies alternate sources of funding if available for services as indicated.
  • Assists participants to navigate health care system and access appropriate services and resources.
  • Addresses complex communication and planning issues as participant receives services across the continuum (in particular for patients with multiple specialists and services).
  • Leads and supports transition and discharge planning for participants moving between levels of care.
• Monitors Progress Toward Goals.
  • Initiates care plan modifications as necessary through monitoring and evaluation to accommodate changes and encourage optimal health and safety over time.
  • Follows the participant over time, across continuum of care to measure effectiveness of the plan.
  • Adapts plan to meet changing needs.
  • Communicates with participant, family and healthcare providers about changes in plan.
  • Documents all encounters thoroughly in timely manner in designated data system.
• Provides qualified professional oversight as needed to ensure appropriate care plan development.
  • Participates in work groups and committees as appropriate
  • Supervises and delegates to care management support staff tasks that contribute to the plan.
  • Participates in staff and departmental meetings and assists with identification and resolution of problems.
  • Communicates issues and decisions relating to committee or project work to other team members, management, and sponsors
  • Works collaboratively with interdisciplinary care management professionals to design and deliver an integrated care plan.
• Other duties as assigned.

Job Requirements

• Associate's or Vocational degree in nursing required and
• Bachelor's degree in nursing preferred
• 2 to 5 years of previous care management experience preferred
• 2 to 5 years of clinical experience required
• Licensed Registered Nurse - MN Board of Nursing required or
• Licensed Registered Nurse - WI Dept of Safety & Professional Services required
• Care Manager Certification preferred
• Valid Driver’s License required upon hire - MN and WI residents must obtain a valid driver’s license in their state of residence within 60 days of employment for some departments upon hire

Physical Demands
Sedentary:
Lifting weight Up to 10 lbs. occasionally, negligible weight frequently
Additional Job Description:

• Monday-Friday position with no weekend or holiday rotations
• Partially remote role that will office from home and serve patients in their homes and communities across the Twin Cities metro on occasion. Mileage reimbursed.
• Benefit eligible position