Job Description

Registered Nurse Care Coordinator, Quality Management

Full TIme, 80 Hours Per Pay Period, Day Shift

Covenant Medical Group Overview:

Covenant Medical Group is the employed and managed medical practice organization of Covenant Health, providing comprehensive care across East Tennessee. With more than 300 physicians and advanced practice providers in 20 communities, our team delivers expertise across a broad spectrum of specialties from primary care and walk-in clinics to preventive medicine and advanced surgical and subspecialty services. We are committed to offering coordinated, patient-centered care that spans the continuum of health needs, ensuring access to exceptional providers close to home.

The RN Care Coordinator II is responsible for integrating evidenced based clinical practice into the patient care setting, coordinating education of staff and patients and serving as a clinical resource and consultant to the health care team. The RN Care Coordinator II is responsible for promoting patient care coordination and quality through the collaborative development of practice guidelines and clinical pathways that support quality improvement activities. The RN Care Coordinator II actively seeks opportunities in research designed to identify best practices. The RN Care Coordinator II has the responsibility, accountability and authority for providing comprehensive care coordination and knowledge to plan, implement, monitor and evaluate the outcomes of care for the designated patient population. The RN Care Coordinator II reports directly to the Manager of Quality Management at the corporate level.

Responsibilities

• Utilizes case finding criteria to screen patients and gather information from the medical record, provider documentation and communication, patient/family as well as other sources to develop a comprehensive plan for the patient that will meet identified needs.
• Facilitates timely documentation review with the Clinical Documentation Improvement (CDI) specialist, as necessary to ensure appropriate clinical documentation is available in the patient’s medical record to guide the care team in determining the expected plan of care.
• Utilizes the care coordination process to evaluate with the patient, care givers and provider, the patient’s progress in meeting care management goals.
• Modifies the case management plan to meet the changing needs of the patient’s clinical condition. Secures needed resources via a multidisciplinary approach to care management strategy to assure timely, efficient and cost effective services.
• Researches, designs and implements practice guidelines and clinical care designs in collaboration with providers, nursing and other members of the health care team for assigned population.
• Identifies specific objectives, goals, and actions to meet the patient’s identified needs.
• Collaborates and communicates effectively with the provider and other members of the health care team to plan and implement the care of the patient in a timely manner. Documents results of communication in the medical record.
• Instructs the patient in accordance with the plan of care providing education on medications, treatment plan, future appointments and modalities as necessary to promote health and continuity of care.
• Participates in daily multidisciplinary discussions and ensures appropriate disciplines are available.
• Collaborates directly with the Quality Manager to ensure the staff adheres to sound clinical practices assisting in the development of educational activities for staff or patients as needed.
• Works closely with the provider to identify the necessary resources and ensures the appropriate utilization of same.
• Communicates effectively with provider offices, home health agencies, rehabilitation facilities, long term care facilities, and third party payers to identify goals to assure that patients receive the most appropriate, cost effective and efficient means of care. The RN Care Coordinator provides documentation in the patient’s medical record to communicate the goals and transition plan for the patient.
• Executes and documents the Care Coordination activities and interventions related to specific patient goals.
• Serves as liaison to provide communication with the patient/family, provider and the health care team.
• Coordinates, organizes, secures, integrates, modifies and documents resources needed to accomplish goals related to the patient’s Plan of Care.
• When necessary, serves as the “brokering” agent to secure coverage for needed community services.
• Gathers sufficient information from all relevant sources and documentation regarding the care management plan and activities and or services to enable the Care Coordinator to determine the plan’s effectiveness.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to appropriate next level of care.
• Identifies, communicates and initiates actions to mitigate variances in the patient’s process of care.
• Stays abreast of most recent changes in quality related to HEDIS measures, CMS Conditions of Participation, MIPS and other regulatory requirements to assist in compliance for assigned population.
• Monitors patient population for potential Transitions of Care and proactively initiates actions to support the associated needs.
• When necessary, serves as the “brokering” agent to secure coverage for needed community services.
• Mobilizes resources and coordinates the effort of the health care team to achieve a positive patient transition to next appropriate level of care.
• Ensures Multidisciplinary approach with care giver and health care team to successfully achieve the desired outcomes and goals.
• Evaluates the Care Management plan and modifies or changes the plan as needed to meet the patient’s needs.
• Utilizes statistical analysis techniques to measure clinical and fiscal variances from established patient care guidelines, care designs, protocols and quality measures.
• Develops reporting mechanisms to communicate outcomes to providers and other members of the health care team.
• Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team.
• Maintains ongoing fiscal awareness by communicating outcomes to all stakeholders at specified times.
• Monitors and addresses outcome variances concurrently.
• Identifies causes of outcome variances and implements actions to improve the variances; evaluates corrective actions for improvement.
• Proactively seeks the most efficient, cost-effective ways to provide appropriate care.
• Conducts research to identify “best” practices for achieving patient outcomes.
• Participates in quality improvement initiatives for assigned population.
• Addresses end of life issues as they arise with the provider, family and other members of the health care team.
• Maintains patient Privacy information with other facilities, services and departments involved in Interdisciplinary Planning Process.
• Serves as patient advocate in performing care coordination duties.
• Provides care coordination services within the scope of practice as a registered nurse meeting all required standards both legal and regulatory.
• In collaboration with clinic personnel and other members of the health care team, researches, plans, develops and assists in patient education; requires return demonstration to ensure patient and family understanding of inpatient plan of care as well as post discharge needs
• Participates in staff development, orientation, and unit meetings through mentoring, consultation, educational presentations and clinical direction.
• Actively participates in the supervision, education, orientation, and evaluation of care coordination staff as needed.
• Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
• Performs other duties as assigned.

Qualifications

Minimum Education:

Bachelor’s degree in Nursing or related field OR certification as listed below.

Minimum Experience:

Four (4) years of acute care nursing experience; a minimum of three (3) years of experience in area of assigned responsibility.

Licensure Requirement:

Current Tennessee RN License. Current certification in Case Management, CCM, ACM or CPHQ OR Bachelors degree in Nursing or related field.