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RN Care Coordinator

Location: Amsterdam, NY
Job # 10493695

RN Care Coordinator
Location: Amsterdam, NY                                             
Reports To: RN/CQI/Clinical Manager                                                                     
Physical Requirements: Normal Office Environment
Hours of Work: Full Time, 40 hours per week. Flexible schedule needed, mostly days, with evenings/weekends a must.
Job Qualifications:
  • Registered Nurse with valid NYS RN license required
  • Basic life support and Bachelor’s Degree and/or relevant experience preferred
  • Minimum of 3 years experience in clinical or community resource settings
  • Care coordination and/or case management experience is desirable
  • Evidence of essential leadership, communication, education and counseling skills
  • Proficiency in communication technologies(email, cell phone, etc)
  • Highly organized with ability to keep accurate notes and records
  • Experience with health IT systems and reports is desirable
  • Local knowledge about and connections to community health care and other medical and social community based organization resources is desirable
  • Must be able to read, write and speak the English language
  • Bilingual is a plus
  • Valid NYS driver’s license
Major Responsibilities:
  • Responsible for planning, organizing and coordinating the clinical care for Primary Care patients at New Dimensions in Health Care.
  • Coordinates patient care services for patients across the continuum of care through collaboration with patients, families, health care providers and other community based organizations to enhance care coordination and link patients to the appropriate services(A large portion of care will be provided telephonically)
  • Increases utilization of preventive care by providing pre-visit and follow up contact with patients as indicated to ensure compliance with care recommendations, medications, lab/x-ray, specialist visits, referral tracking, PCP visits, dieticians, etc., and updates the electronic health record accordingly.
  • Utilizes electronic health record reports to identify and reach out to patients who are overdue or in need of preventive care
  • Provides telephone advice under direction of provider, triaging urgent calls/messages and emergent calls/messages
  • Coordinates transitions of care between the inpatient and ambulatory settings.
  • Coordinates care with hospital, ER, consulting physicians (referral tracking), home health care agencies, and community resources to decrease ER Visits, Inpatient admissions and re-admissions, and encourage preventative health.
  • Collaborates with, and refers to the RN Case Manager to assist patients in meeting goals for self-management, teaching them how to do self-management tasks, and reporting abnormal findings to the Provider and RN Case Manager.
  • Collaborates with RN Case Manager in providing non-face to face Chronic Care Management to identified population of patients and maintains appropriate documentation in the electronic health record.
  • Participates in our patient-centered medical home, aiding in the development of office workflows for the medical home, and collaborating with team to develop a standard of care for preventative services, chronic care management, and transition of care.
  • Assesses barriers when patients are not meeting treatment goals, not following treatment care planning, or have not kept important appointments
  • Assists in facilitating implementation of clinical best practices and quality improvement initiatives.
  • Participates in staff/team meeting and activities
  • Effective verbal, written, and telephonic communication skills are essential.
  • Organizational skills to multi-task, set priorities, and efficiently complete assigned work.
  • Conducts and submits reports within required time frames.
  • Maintains competency in areas of responsibility to ensure quality of care.
  • Maintains patient confidentiality; is comfortable handling sensitive personal information.
  • Performs other duties as specified by supervisor.
Disclaimer The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification.  They are not intended to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Liberty reserves the right at its sole discretion to amend its policies, programs and/or guidelines, including the contents of this job description, at any time without prior notice.
We are proud to be an Equal Opportunity/Affirmative Action Employer regardless of Race/Color/Religion/Age/Sex/National Origin/Marital Status/Disability/Veteran Status/Sexual Orientation/Gender Identity/Genetic Information and all other categories covered by law. We maintain a drug-free workplace and perform pre-employment physicals and substance abuse testing.
Liberty was founded in 1957 by parents of children with developmental disabilities who wished to establish special education programs in the local community. Celebrating 60 years of quality services in 2017, the organization offers vocational, residential, day, family support and health-related services. We are headquartered in Amsterdam, NY with sites located throughout Montgomery County.
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