RN CARE COORDINATOR - Population Health

Employment Type:

Full time

Shift:

Day Shift

Description:

** This position is located at the Westchester office and in LUHS Primary Care clinics or inpatient hospitals **

Join our dynamic team and use your nursing knowledge, skills and abilities to their fullest!

You will be providing care management and coordination in the ambulatory setting. As part of an interdisciplinary team, you will be central to working with Medicaid, Medicare and Commercially insured patients to support them in their care journey.

Provide comprehensive and individualized access to physical health, behavioral health, and supportive community and social services, ensuring patients receive the right care in the right setting at the right time. Empower patients and their families/caregivers to be active participants in their care, through patient-friendly education and informed shared decision-making that is based on cooperation, trust, and respect for each individual's health care knowledge and health literacy, values, beliefs, and cultural background. Encourage patient self-management.

Coordinate the plan of care. Ensure accountability for coordinating, providing, and monitoring a patient's/family's needs, including prevention, wellness, medical and behavioral health treatment, care transitions, and access to social and community services through the creation of an appropriate individual plan of care that meets the needs of the patient and the family. Oversee the patient's Plan of Care within his/her panel for a designated timeframe e.g. 30, 90, 360 days determined by the severity of illness and intensity of services required for coordination and outcome achievement.

Utilize population-based tools to support and monitor wellness and care goals for each patient, aimed at preventing illness and improving individual well-being, clinical outcomes and quality of life while managing multiple chronic illness conditions. Interface with providers across the continuum of care via face-to-face interaction, phone conversations, email, fax and text messaging.

Case manage patients with complex, chronic medical and psychosocial issues. Perform utilization management strategies for those cases managed using the lightest and most accurate resource to achieve clinical and financial outcomes outlined by payers. Collaborate with members of the health care team to achieve the clinical and financial outcomes. Use evidence-based practice to build the plan of care. Partner with patients to ensure outcome achievement.

Professional Development: Demonstrate leadership behaviors that enhance and support team functions. Maintain competences and participate in continuing education for self and development of colleagues and students. Seek opportunities to promote self-education, certification, and awards programs. Create opportunities to advocate for the role of the professional nurse as a key member of the multidisciplinary team.

Works with relevant stakeholders to ensure smooth transition across care continuum. Works as part of an Inter-professional team including Social Workers and Pharmacist to develop patient centered plan of care.

Position Requirements:

• Minimum Education:

Required: Bachelor's Degree

Preferred: Master's Degree

Specify degrees: BSN

• Minimum Experience:

Required: 3-5 years of experience as an RN

Preferred: 6-10 years of experience as an RN

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran