Continuing Care Coordinator RN

Job Summary and Responsibilities
As a RN Care Coordinator, you will be a central figure in patient care, seamlessly navigating the healthcare journey to achieve optimal outcomes and an exceptional patient experience.

Every day, you will strategically assess, plan, and facilitate comprehensive care across the continuum, expertly advocating for patients while collaborating with physicians, nursing, departments, insurers, and post-acute providers to ensure timely, high-quality transitions.

To be successful in this role, you will possess strong clinical acumen, exceptional communication and advocacy skills, and a strategic mindset, all driven by a passion for optimizing patient care across every touchpoint.

• Assessment
  
  
  Works with “at risk” patients and families on self-management 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.
  
  
  Following evidence-based care pathways
  
  
  Coordinating care across multiple provider sites and interdisciplinary teams
  
  
  Working with patients to create a plan of care for health behavior change:
  
  
  Assessing and working on the patient’s readiness to change, the importance of change, and confidence in ability to change
  
  
  Helping the patient to identify and overcome barriers
  
  
  Setting short and long-term goals for self-management of chronic disease, empowering the patient, family and /or caregiver to achieve maximum levels of wellness and independence.
  
  
  Referring to appropriate services when applicable including but not limited to community resources and services to address the established goals or desired outcomes.
  
  
  Anticipates and identifies variances in the care process related to those identified needs. Modifies plan of care to resolve unexpected care needs.
• Leadership
  
  
  Leads an interdisciplinary healthcare team in the management of high risk 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.
  
  
  Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provides ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly. Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.
• Critical Thinking
  
  
  Assists patients and or caregiver 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.
  
  
  Monitors member's compliance with scheduling and keeping PCP and specialist appointments identifying patterns of nonadherence and coordinates scheduling of needed member appointments
  
  
  Reports to the Care Coordination Manager or Director for Quality and Utilization regarding member status and identifies any potential risk management.
• Relationships
  
  
  Leads efforts to optimize care coordination across the care continuum, building and maintaining positive relationships with the healthcare team.
  
  
  Assumes responsibility, authority and accountability for patient load, assisting other coworkers when requested or as the need arises.
  
  
  Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner.
• May also be required to meet patients and or family members either in the community, at home, or other location. Must be able to assess the environment for safety for self and patients and escalate any concerns to the Medical Social Worker, Licensed Social Worker or program manager based on the situation.
  
  
  May also be required to:
  
  
  Concerns or complaints
  
  
  Research and recommend appropriate follow-up and or corrective measures
  
  
  Identify opportunities to achieve department process excellence through a thorough analysis of available data and involvement of interdisciplinary teams
  
  
  Department Audits
  
  
  Assist with audits at the direction of the manager
  
  
  Consolidate audit results and provide analysis of results
  
  
  Day to day operations:
  
  
  At the direction of the manager, assist with hiring by organizing peer interviews
  
  
  Work in conjunction with management to ensure daily performance of staff supports effective, safe and efficient patient care and department operations
  
  
  Mentor new employees meeting weekly with the employee and or leadership to track progress, ensure appropriate communication with team members
  
  
  Identifies and actively participates (or leads) projects to assist with team self-actualization
  
  
  Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project, provides ongoing support to team members in collecting, interpreting, and communication of data, and developing action plans accordingly.
  
  
  Team conferences
  
  
  attend and participate at interdisciplinary team meetings
  
  
  Initiate patient care conferences when needed.
  
  
  Committee participation outside of operational departmental work

Job Requirements
Required

• Associate Of Arts Nursing and 2 years relevant experience or advanced degree, upon hire and
• Registered Nurse: TN, upon hire

Preferred

• Bachelors Of Science Nursing and 3 to 5 years, upon hire

Where You'll Work

CommonSpirit Memorial is an award-winning, not-for-profit, faith-based health care organization dedicated to the healing ministry of Jesus Christ. Founded by the Sisters of Charity of Nazareth, we offer a comprehensive continuum of care, from preventative and primary care to acute hospital services specializing in cancer, cardiac, neuroscience, stroke, and orthopedic services. Our commitment to excellence has earned us top prestigious recognition repeatedly from U.S. News and World Report, PINC AI™, CMS, Healthgrades®, Leapfrog, and most recently as one of the Best Places to Work in Tennessee. We are proud to serve Southeast Tennessee and Northwest Georgia with the expertise of 4,700 employees and nearly 500 affiliated physicians.

Total Rewards

Depending on the position offered, CommonSpirit Health offers a generous benefit package, including but not limited to medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings, as may be amended from time to time. For more information, please visit our Total Rewards.

Unless directed by a Collective Bargaining Agreement, applications for this position will be considered on a rolling basis. CommonSpirit Health cannot anticipate the date by which a successful candidate may be identified.