Job Type:RegularScheduled Hours: 40Job Summary:Reports to the RN Manager of Care Coordination, the RN Care Coordinator (OCC) works collaboratively with providers, interdisciplinary staff, and clinical associates, in person and telephonically, at any/all SEP offices to support patients with chronic conditions and/or complex needs according to guidelines established by SEP and other clinical programs such as PCF etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns. DIMENSIONS:A RN Care Coordinator- Office Care Coordinator works in person and telephonically as a member of the interdisciplinary team. A RN Care Coordinator- Office Care Coordinator understands and adheres to established best practice care management standards of care. A RN Care Coordinator- Office Care Coordinator understands and coordinates care using evidence based clinical guidelines for chronic disease management.Job Description:Job Title: SEP - RN Care Coordinator (OCC)DUTIES AND RESPONSIBILITES:Documents in chart appropriately utilizing care management documentation.Provides patient care through collaborating with patients, providing education and clear direction to the patient and address patient concerns regarding care. The RN engages in critical thinking to meet patient needs.Support Chronic Disease Management and Patient Care Needs:-Identify patients with chronic disease, rising risk concerns, social, financial, or educational needs for care management services.-Respond to provider referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or blood pressure, Mental Health Integration referral, complex needs)-Evaluate and collaborate with patients’ and families to determine readiness to change and resources for support.-Monitor compliance with plan of care and problem solve barriers to patient self-management.- Provide support for patient and family issues, resource needs, and answering general healthcare questions.- Do ADL assessment and home safety assessments based on patient interview.- Identify and place order for services such as HH when patient has identified need- Utilize teach back method for pts who have no medical necessity to justify home health.- Assess need and provide basic diabetic teaching (glucose meter testing, etc.)-Assess need and obtain required order for patient to receive disease management teaching or counseling (MD referral required for billing)- Document RN Care Coordinator interventions in Epic within care management documentation.- Refer non-nursing functions, such as assisting patients with completion of Medicaid, disability, pharmacy program or other eligibility applications, and scheduling appointments to designated resources in the region.-Coordinate with care managers in other settings as appropriate.- Carry out assessments and make decisions on his or her own before seeking the support of a supervisor.- Assist providers, patients, and families with Advance Care Planning- Explain results from screening based on protocol and guidelines.- The RN is expected to perform medication reconciliation for each patient on their panel.Provides ongoing management for chronic conditions, working with patients to meet healthcare goals per cadence expectations.Patient Education:-Provide education and pre-printed, SEP approved educational materials as needed, or at provider or patient request- Work collaboratively with patients to assess needs and develop a patient education plan of care.- Answer clinical questions related to patients’ chronic health conditions.- Provide group education for established patients.-Must understand professional boundaries and appropriately refer diagnostic questions to MD.- Refer patients appropriately when needs for mental health, pharmacy, social work, respiratory therapy etc. are identified.- Work telephonically with patients as needed.Ensures complete and accurate information in the Electronic Health Record.Coordinate referrals to community resources (e.g. home health, Durable Medical Equipment, support groups)-Forward written physician orders for treatment- Assess patient for additional needs, develop nursing plan of care and contact physician for order-dependent items.Coordinate scheduling of appointments when support is needed for a multitude of disciplines.Maintains adequate level of resources for care coordination.OSHA and HIPAA compliance.Assists with completion of patient requests in a timely manner.Timely and accurate complete charting of all patient information.Other duties and responsibilities as assigned are complete in a timely and accurate manner. Maintain good working relationships communications with all interdisciplinary team members, management, and utilization review staff for coordination of care and care transitions.Work with providers, interdisciplinary staff, and office staff to identify appropriate patient population for advance care planning.Work directly with patient to educate, provide resources, and manage their disease processes.Manage and perform home visits with patients as needed if a component of care management expectations.Attend meetings as required.In office support for nursing tasks such as: PPD, IRIS Exams, CGM starts, etc.Collaborative communication with office staff to be available for warm hand offs and immediate patient needs.Assessment of medication affordability and assisting patients with identified needs.REQUIRED SKILLS AND KNOWLEDGE: Ability to manage and prioritize multiple tasks.Knowledge of electronic Health Records – (EPIC)Knowledge of Excel, Word, Outlook and PowerPoint and the ability to learn other computer skills as needed.Good organizational skills.Work professionally with doctors, hospital administration and management, SEP associates and the public.Organized, neat and self-motivated.Warm personality with concern for others.Excellent verbal and written communication skills.Excellent interpersonal skills.Ability to affect change.Ability to perform critical analysis.Self-directedWork well telephonically as well as face to face.Can work autonomously.Be familiar with motivational interviewing with patients.Positive attitudeQuest for learning and excellence.OTHER REQUIRED SKILLS AND KNOWLEDGE:Previous Quality Assurance experience preferredEDUCATION: -Degree in nursing (ADN or higher)-Current Driver’s License in good standing and reliable and insured transportationLICENSES AND CERTIFICATIONS:-Kentucky Registered Nurse (RN) Compact License (or any RN compact license) required.-Care Management Certification preferred.YEARS OF EXPERIENCE:-Minimum of 3 years nursing experience or current care management position held within SEP Clinical Transformation.-Demonstrated knowledge of anatomy and physiology, pharmacology, etc. -Ambulatory and/or care management experience.FLSA Status: Non-ExemptRight Career. Right Here. If you have a passion for taking care of the community and are interested in Healthcare, you will take pride in the level of care we provide at St. Elizabeth. We take care of patients and each other.