The RN Care Coordinator (Health Coach) is a Registered Nurse who facilitates patient continuity of care with the healthcare team. Under the clinical direction and oversight of the Primary Care Physician, the Care Coordinator coordinates care for high risk/complex patients by collaborating with the patient, family, physician, nurses, and other members of the healthcare team to identify needs and expedite appropriate, cost effective care. S/he assists in the development of the patient’s care plan and collaborates with the Primary Care Physician to provide leadership in issues of outcomes management, disease management and prevention, and development of improved strategies to benefit high risk patients. The Care Coordinator will serve as the patient’s primary conduit to the primary care provider as they help coordinate necessary services both within and outside the practice, coordinating care from a variety of sources—physicians, specialists, home care providers, rehab centers, pharmacists, etc. They will engage patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt life-long healthy behaviors.
- Contact ACO members to determine if there is a need for case management intervention based on guidelines, protocols and timeframes established for the applicable clinical program.
- Provide care coordination according to program descriptions including member education, follow up on a timely basis and eliminating barriers to care.
- Conduct comprehensive assessments that include the medical, behavioral, pharmacy, and social needs of the member. Review data for services the member has received and identify gaps in care based on clinical standards of care.
- Based on assessment of members needs and environment, identify applicable barriers, problems, goals, and interventions that will close gaps in care and address those needs and improve or maintain the health status of the member.
- Successfully engage member to develop an individualized plan of care to promote healthy lifestyles, close gaps in care, and reduce unnecessary ER utilization and hospital readmissions. Develop and coordinate the individualized plan of care with the member, member’s family, providers and community agencies as applicable. Involve other staff to support the individualized plan of care based on identified needs of the member
- Follow-up with the member according to established clinical program protocols and timeframes to monitor their status, evaluate the effectiveness of the individualized plan of care, and identify new needs. Modify the individualized plan of care or case status based on the status of the member.
- Document care coordination activities based on the DVACO clinical platform in a timely and accurate manner; assuring the DVACO the ability to comply with professional documentation standards, compliance of DVACO contracts, and quality data collection.
- Perform duties and responsibilities in accordance with the philosophy and standards of the DVACO, including conveying courtesy, respect, enthusiasm, and a positive attitude through contacts with staff, health plan members, peers, and external contacts.
Primary Customers or Key Working Relationships: Patients of the DVACO, Primary care Providers, Medical Specialists, Hospital Case Managers, Home Health Agencies, Pharmacies, DVACO Program Managers, Supervisors and Support Staff, Community Agencies/Providers
Graduate of an accredited School of Nursing, Bachelors degree required, MSN preferred.
Licensures and Certifications:
- Valid Pennsylvania RN licensure required
- Bachelor’s degree in nursing required
- Case Manager (CCM) certification preferred
- 5 years experience in clinical, utilization management, home care, discharge planning, and/or case management required QUALIFICATIONS:
- 3 years experience in a managed care environment preferred
- Ability to interact with physicians and other health care professional in a professional manner required
- Computer proficiency required.
- Excellent verbal and written communication and interpersonal skills required
- Ability to prioritize daily tasks and caseload activities to meet patient needs and turnaround times
- Knowledge of managed are models financial reimbursement systems, clinical case management processes and utilization management issues
- Knowledge of NCQA (PCMH) guidelines for care management
- Occasional travel within 50 mile radius of Philadelphia.
- Possibility of offsite meetings at provider offices, community agencies or other clinical settings. Occasional seminars or training sessions in the Philadelphia area.
If interested, please apply online at https://www.mainlinehealth.org/careers, Job ID 45888. Applicants must certify that they have not used tobacco products or nicotine in any form in the 90-days prior to submitting an application to Main Line Health. This will be verified during pre-employment testing. We are an Equal Opportunity Employer. Please, no agency calls.