RN Care Coordinator, Care Management (Inpatient)

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We are recruiting for a mission-driven RN Care Coordinator, Care Management (Inpatient) to join our team! We're with you for life's journey. At Denver Health, purpose isn't just something we believe in-it's something we live every day, for life's journey. Our Values Respect | Belonging | Accountability | Transparency Department Hospital Care Mgmt Job Summary Under general supervision, the RN Hospital Care Coordinator is responsible for facilitating and coordinating the care delivered to an assigned group of patients through multidisciplinary and patient/family collaboration to ensure quality and cost-effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment, planning, support, and evaluation of patient care and related outcomes. Activities to be performed are screening for high risk and transition of care needs, interviews with patient/family, and progression of care facilitation with the healthcare team. The Care Coordinator is an active contributor in the development of systems (e.g., care maps, clinical paths) to improve the care of assigned patient populations and to move along the continuum. Essential Functions : Review Status and Level of Care Management - Ensures barriers are identified and escalated as needed. (35%) Clinical Care Screening and Resource Management - Upon referral conducts an initial clinical and psychosocial screen through review of the patient's medical record, interview with the patient/family members and discussion with the physician and other healthcare team members. - Monitors the patient's treatment plan, medical goals and prescribes services to facilitate provision of services/referrals that are needed to meet the needs of the patient during hospitalization thus driving the clinical care process. Coordinates any needed referrals, PT/OT, wound care, dietary, pharmacy, cardiac rehab, etc. to facilitate efficient patient flow through the hospital system. - Participates in Care Conferences and Care Rounds as required and assists with the development of care plans that will meet the patient's current and continuing healthcare needs. - Ensures that services are appropriate for the patient's level of care and identifies any test/procedure that could be done as an outpatient and discusses alternative with the physician. (35%) Risk Assessment and Transition of Care Screening - Identifies all readmissions within 30 days and initiates a readmission risk assessment within 24 hrs of identification. - Communicates the results of the risk and transition of care screening processes to the physician(s) and other healthcare team members, including external Case Managers and community-based clinic providers, as identified. - Generates a referral to the assigned Clinical Social Worker partner for implementation and collaboration of the transition of care plan throughout the hospital stay, as needed. - Supports the development and implementation of the patient's transition of care plan working collaboratively with the Clinical Social Work partner. - Communicates any clinical changes that would alter the transition of care plan to all healthcare team members, especially the Clinical Social Worker. - Ensures state and federal regulations/rules and insurance company requirements/processes are met. - Documents the initial transition of care screening information in the patient's clinical record according to departmental policies and procedures. (30%) Education : Associate's degree Completion of a nursing education program that satisfied the licensing requirements of the Colorado State Board of Nursing for Registered Nurses Required Work Experience: 3 years of clinical inpatient experience Required Licenses : BLS-Basic Life Support (BLS/CPR) - AHA - American Heart Association Required Registered Nurse - DORA - Department of Regulatory Agencies Required CCM-Certified Case Manager - ANSI - American National Standards Institute Preferred Knowledge, Skills and Abilities : Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment required. Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently. Evidence of leadership, creativity, integrity and initiative required. Ability to work effectively in a team environment. Experience with windows-based computer programs and ability to use computer for data analysis and data display required; must be able to type 35 words/minute. EPIC experience a plus. Shift Days (United States of America) Work Type Regular Salary $86,300.00 - $133,800.00 / yr

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