RN Complex Care Coordinator - Transitional Care Management - Full Time
RN Complex Care Coordinator – 1.0 FTE Days
Care Management is seeking an RN Complex Care Coordinator to support medically complex patients across ProHealth Care’s clinic network and care continuum. This role primarily supports adults age 65+ with chronic conditions, cognitive concerns, transportation barriers and ongoing care coordination needs.
Schedule:
Monday through Friday, 8:00 a.m. – 4:30 p.m.
No weekends or holidays
This position includes in home visits
Schedule Highlights:
• Combination of telephonic outreach and home visits
• Collaborative interdisciplinary team
• No direct bedside or hands-on nursing care
This position is ideal for an RN who enjoys relationship-based care coordination, autonomy, critical thinking and helping patients navigate complex healthcare and social needs throughout the continuum of care.
Responsibilities Include:
• Coordinating care for medically complex patients across ambulatory and community settings
• Supporting patient transitions throughout the continuum of care
• Identifying and addressing barriers impacting self-management and healthcare access
• Collaborating with providers, clinic teams, social work and community partners
• Conducting telephonic outreach and home visits
• Assisting patients with transportation and community resource coordination
• Utilizing motivational interviewing and patient-centered care planning
• Managing a dynamic caseload while reprioritizing throughout the day
• Completing accurate and timely Epic documentation
Ideal Background:
• RN experience in care coordination, ambulatory care, geriatrics, home health, transitional care or community health
• Strong communication, organizational and critical thinking skills
• Comfort working independently with a high level of autonomy
• Passion for supporting older adult and medically complex patient populations
• Epic experience preferred
Learn more about ProHealth Care: https://www.prohealthcare.org/
Job Summary
• Collaborates with physicians, advanced practice providers, and ancillary health care team members to coordinate system and community resources to maximize advocacy for patient and family care in achieving the most effective outcomes
• Advocates for the patient by providing support and resources in order to reach optimal function and health, in an appropriate environment
• Develops a patient-centered plan of care to optimize wellness and quality of life, operating from an in depth understanding of their unique meaning of health, illness and disease
• Maintains a broad perspective of the patient’s journey across the Continuum of Care in order to assist with navigation and coordination of care
Responsibilities
• Assists the patient in the examination, clarification and communication of their values
• Assesses patient activation: the knowledge, skills and confidence they have in managing their own health and health care
• Employs Motivational Interviewing to assist patients in identifying obstacles to self-management and develop patient-centered goals
• Promotes healing by helping the patient and family cope with the fears and concerns that accompany life and health changes
• Fosters a strong bond and facilitates partnership and communication between the patient and the primary care provider
• Creates an environment that supports life-long learning that empowers patients to self-manage
• Provides evidence-based patient education and assists in shared decision-making
• Applies a flexible and creative approach to problem solving
• Provides care coordination and collaboration during patient transitions across the Continuum of Care
• Identifies barriers to disease self-management and self-care, including Social Determinants of Health
• Facilitates patient access to PHC or community resources for disease-specific education, self-management and social support
• Functions independently and possesses the internal discipline/drive to guide care for patients with complex health needs
• Completes all EHR documentation accurately, timely and efficiently for regulatory compliance
• Demonstrates effective use of healthcare and information technology resources
• Attends appropriate educational opportunities and shares knowledge and experiences with others in formal and informal settings. Maximizes personal growth and develops an individual educational plan.
• Demonstrates a commitment to the values of the ProHealth Experience: Respect, Relationships, Communication, Collaboration and Excellence
Why Join ProHealth Care:
We have nearly 5,000 dedicated clinical and non-clinical employees and physicians who work together every day to serve the health and well-being of our community. At ProHealth Care everyone contributes to the care our patients receive. And, everyone is treated with kindness and respect in our welcoming environment.
This Position Will Offer You:
- Engaging and community focused culture
- Competitive Salaries
- Opportunity for professional career growth
- Robust benefits including: Generous PTO; Choices in insurance; HSA; Tuition reimbursement; immediate 401K match; discounted tickets to various entertainment, social and sporting events
ProHealth Care is an equal opportunity employer and is committed to an inclusive work environment and values the perspectives of our people. We maintain a drug-free workplace and perform pre-employment substance abuse testing. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.
Nearest Major Market: Waukesha
Nearest Secondary Market: Milwaukee