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RN Ambulatory Care Coordinator

Company: Beaumont Health
Location: Royal Oak
Posted on: September 15, 2022

Job Description:

Remote positionGENERAL SUMMARY:Provides care management and care coordination for patients with complex conditions and those with mild to moderate chronic illness. In partnership with the primary care practice leadership team, the Ambulatory RN Care Coordinator leads care management and population management functions within the team through process improvement workflow redesign, providing assistance with training, and delegating to other members of the team. Responsibilities include collaboration with members of the health care team to ensure the delivery of quality, efficient, patient centered, and cost-effective healthcare services.BENEFITSBeaumont offers a comprehensive benefits package to meet your financial, health and life-work balance goals.

NEW On-demand pay program powered by PayactivGenerous paid time off, holidays and flexible schedulingOur employees receive special discounts on a wide range of products and servicesExceptional health, dental, vision and prescription drug insurance plansRelocation assistance Generous retirement savings, disability insurance, identify theft protection and even home and auto insuranceFree onsite parking at all campusesESSENTIAL DUTIES:1. Using a variety of methods and tools, identifies targeted high-risk population and chronically ill population within practice sites. Assesses the healthcare, educational, and psychosocial needs of the patient/family. Uses appropriate assessment tools such as depression screening, functionality, and health risk assessment.2. Collaborates with Primary Care Physician, patient, and members of the health care team, to assess, develop and implement an agreed upon plan of care. Participates in continuous quality improvement to enhance care management in the office setting. Monitors patient/family response to plan of care and revises the care plan as indicated. Provides self-management support with a focus on empowering the patient/family to build capacity for self- care. Ensure support for advanced directives and advanced care planning.3. Conducts comprehensive assessments to identify the members needs, self-management goals, functional and/or cognitive impairment, psychosocial issues, environment, and areas of risk or barriers that may impact the patients adherence to the care management plan.4. Using evidence-based guidelines and clinical tools, identifies patients with chronic conditions, and gaps in clinical care. Implements systems to ensure necessary care is completed and monitors individual patient progress and population health.5. Coordinates patient care by linking patients to resources. Provides follow up with patient/family when patient transitions from one setting to another. Completes post hospital discharge calls including medication reconciliation,coordinates physician follow-up appointments, symptoms assessment and patient education/ discharge instructions, and problem-solves barriers to compliance.6. Maintains required documentation for all care management activities. Works with practice and Physician Organization/Accountable Care Organization leadership to continuously evaluate processes, identify problems, and propose/develop process improvement strategies to enhance the Patient Centered Medical Home delivery model and meet value-based reimbursement payer program requirements.7. Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.8. Provides education on management of chronic conditions and enhances the members self-efficacy to prevent progression or exacerbation of chronic illness and promote healthy behavior change. Coordinate care transitions and monitoring of high-risk members following hospital and sub-acute discharges to ensure timely follow-up with primary care and prevent readmissions.This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.STANDARD REQUIREMENTS:1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process.2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.3. Supports and adheres to all Beaumont Healths customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code.4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information.5. Supports and participates in a collaborative team-oriented environment cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.6. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.7. Completes all required compliance standards that may be department specific and/or identified by the organization.8. Maintains current licensure, registration and/or certification, as applicable, at all times.STANDARD QUALIFICATIONS:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.A. Education / Training: Graduate of an accredited school of nursing. Bachelor of Science in Nursing degree required.B. Work Experience: Minimum two years RN experience in a clinical care setting. Three to five years experience in care management, home care and/or discharge planning preferred. Experience in an ambulatory practice setting preferred.C. Certification, Licensure, Registration: Requires a current, unrestricted license to practice as a registered nurse in the State of Michigan. Certification in care management preferred.D. Other Qualifications: Working knowledge of 3rd party requirements, excellent interpersonal and communication skills. Ability to act in an autonomous, self-directed manner in a fast-paced, ever-changing environment. Knowledge of chronic disease, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education. Excellent assessment and triage skills Ability to manage complex clinical issues utilizing assessment skills and protocols Ability to affect change, work as a productive and effective team member, to be flexible, and adapt to needs/priorities Proficient in computer skills and applications including Excel workbooks Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, and religious and cultural ideals.WORKING CONDITIONS:A. Physical Effort: Position requires incumbent to occasionally perform physical activities necessitating ability to push/pull objects up to 20 pounds. Mobility skills such as walking and standing along with performing manual dexterity and coordination functions required.B. Work Environment: Incumbent may be occasionally exposed to blood, body fluids, and hazardous substances.Beaumont Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.Required
Preferred
Job Industries
  • Customer Service

Keywords: Beaumont Health, Royal Oak , RN Ambulatory Care Coordinator, Other , Royal Oak, Michigan

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