Rn Clinical Coordinator

We Are Different!!

• Opportunity:Provide appropriate, patient-centered care to high-risk, medically vulnerable patients, often suffering from multiple chronic conditions, when and where they need it. This patient-centric, continuous care model delivers clinical, economic, and human benefits.
• Mission: Bedrock Management Services Organization is a group comprised of clinical & operational experts who are championing the digital transformation era, with only one goal in mind; To optimize the patient experience by navigating our patients through our healthcare ecosystem.The mission of Bedrock Management Services Organization is to demonstrate “Caring with a Commitment to Quality” with our wellness ecosystem comprising of Patient Care Medical Group, Patient Care Therapy Group, Home Care, and Population Health. AtBedrock Management Services Organization we are leading the efforts to end fragmented healthcare, offer our partners innovative solutions, and improve the patient experience while providing a much-needed peace of mind.
• Solution: Facilitation of timely interventions when chronic conditions worsen and preempting avoidable emergency department visits and hospitalizations, alleviating social stressors that contribute to poor health, and comforting patients by giving them loving care and letting them know they are not alone.
• Care Settings: Post-Acute Care (PAC), Skilled Nursing facilities, Community/Home Care Patients, Assisted Living

• Provide chronic disease management, remote patient monitoring services, case management, and care coordination in collaboration with Patient Care Medical Group, Patient Care Therapy Group and Home Care interdisciplinary teams to all assigned patients.
• Complete telephonic and/or video nursing assessments and develop nursing plan of care within 48hours of patient referral and/or discharge from acute and post-acute care centers.

• Provide clinical education to patients and caregivers including but not limited to: discharge planning; wound care; disease management; dietary considerations; follow up needs; medication management; activity considerations; and other education as appropriate.
• Review and address all critical RPM values on a daily basis and communicate necessary changes in condition.
• Provide excellent customer service to all clients, patients, and affiliates of Bedrock MSO
• Responsible for reporting and maintaining individual census and appointments daily.
• Schedule and complete weekly assessments with patients, facilities, and or caregivers on a routine basis

• Discover and coordinate services to address the clinical and socioeconomic challenges of patients.
• Collaborate with the interdisciplinary team and provide service referrals as appropriate.
• Responsible for maintaining and updating program intake forms and patient charts.
• Identify and assess patients for changes in condition and report to collaborating providers via fax, email, or telephonic communications.
• Schedule telehealth and/or home visit as appropriate.

• Assist with the office phones through call center; appropriate distribution of messaging
• Responsible for maintaining and completing all assigned documentation within 24hours.
• Responsible for the review and report of all readmissions.