Continuing Care Coordinator RN

Job Summary and Responsibilities

As our Continuing Care Coordinator RN, you will collaborate with physicians, staff, and healthcare professionals within your clinical setting to maintain and improve quality and sustainability within the local market network, focusing on chronic disease management. Every day you will develop individualized care plans based on nursing assessments, provide patient/caregiver education, coordinate interdisciplinary care, monitor patient progress, and implement evidence-based guidelines. You will also manage referrals based on local program criteria and participate in developing workflows and audits, facilitating seamless transitions of care. To be successful in this role, you will be a Registered Nurse with expertise in chronic disease management and care coordination, strong assessment and education skills, and the ability to effectively collaborate with healthcare professionals to implement evidence-based guidelines, driving quality and efficiency within the local market network.

• Works with "at risk" patients and families on selfmanagement support, including performing individual needs assessment, care plan design, education, documentation, implementation, and evaluation of outcomes according to state and national guidelines, policies, procedures, and protocols as required.
• Leads an interdisciplinary healthcare team in the management of highrisk patients referred to the Continuing Care program, facilitating collaboration, communication, and coordination among all responsible parties of the multidisciplinary healthcare team, striving to eliminate fragmentation, duplication, or gaps in care.
• Assists patients and/or caregivers with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services, and necessary procedures, anticipating barriers to care when possible.
• Assesses and works on the patient's readiness to change, the importance of change, and confidence in the ability to change, helping the patient to identify and overcome barriers, setting short and longterm goals for selfmanagement of chronic disease, and empowering the patient, family, and/or caregiver to achieve maximum levels of wellness and independence.
• Monitors member's compliance with scheduling and keeping PCP and specialist appointments, identifying patterns of nonadherence, and coordinating the scheduling of needed member appointments.
• Leads efforts to optimize care coordination across the care continuum, building and maintaining positive relationships with the healthcare team.

Job Requirements

Required

• Associate's Degree in Nursing
• Two (2) years relevant experience OR advanced degree State issued license as a Registered Nurse as applicable to employment

Preferred

• BSN
• Three (3) to five (5) years relevant experience

Where You’ll Work

With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.