Centura Health RN, Registered Nurse - Care Coordinator in Westminster, Colorado

Centura Health Physician Group (CHPG) offers providers a true opportunity to live their calling to care while experiencing the support of a built-in comprehensive network, vast resources, professional growth, trusted leadership, generous benefits and an amazing quality of life with locations that span Colorado and into Western Kansas. CHPG is proud to connect providers and consumers through state-of-the-art technology, clinical resources and professional expertise to help people live healthier. Our coordinated services represent a full continuum of care – from preventive and early diagnoses to leading-edge treatment and life-saving critical care. CHPG’s ability to deliver better health care value is the direct result of combining the best clinical tools, shared resources and medical expertise with a patient-centered approach that emphasizes Centura Health’s mission and commitment to quality, compassion and service.

*JOB DESCRIPTION/JOB POSTING ID: 131675*

*RECRUITER:* CandiceSeng@centura.org

*CLINIC:* 84th Family Practice

*DETAILS:* Full Time

*HOURS:* Days

Occasional travel to other sites to meet the needs of the clinic may be required.

_Position Summary_

For patients experiencing significant or complex healthcare situations, the RN Care Coordinator (RNCC) combines clinical nursing acumen with applied case management expertise to generate highly-individualized care coordination plans. Often, individuals are at-risk for poor health outcomes due to concurrent bio-psycho-social issues and without care coordination interventions; they are likely to use disproportionate levels of unplanned and unnecessary services. The RNCC facilitates planned care collaboration across the team – patient, patient’s family and support system, treating clinicians, delivery systems, community services and others. The RNCC enables the right services, at the right time and place, reinforcing wellness by augmenting the patient’s medical treatment plan with enhanced education, better communications, timely staging and orchestrated transitions across care sites and teams. The RNCC conducts ongoing assessments and observation of the patient’s immediate situation, mitigating developments that may create barriers to maximal wellness and safety. The RNCC directly contributes to resource stewardship, applies evidence-based decision support tools and applications to eliminate medically-unnecessary and duplicative services. The position provides nominal leadership and supports system transformation to value-based services.

_Minimum Education Requirements_

  • Completion of accredited Registered Nursing program BSN Preferred

_Minimum Experience Requirements_

  • 3 years in recent active RN practice, preferably caring for patients with complex or chronic conditions

  • Experience in relevant practice setting requiring coordination of complex care activities, significant independent decision-making & focused action preferred

  • Experience in managed care, population health, case/care management, utilization management or chronic disease management environment preferred

_License/Certifications_

  • Current Colorado RN license in good standing

_Position Duties (essential functions denoted with an * )_

Health Teams

  • Works within a collaborative healthcare team with focus on individuals’ relationships with their medical homes, facilities and centers of care.*

  • Seeks and accepts direct referrals from the healthcare team.*

  • Utilizes available formal and informal methods to case find patients including referrals, health records and histories, registries, stratification tools, care conferences, among others.*

  • Maintains an active case load appropriate to populations served.*

  • Adapts role to population and location-specific requirements.*

Coordination

  • Provides appropriate early and ongoing assessment of individual patient situations for purposes of formulating care coordination plans.*

  • Acts as delivery system liaison, utilizes standardized care and case protocols, develops concise patient summaries, and documents recommendations for use by the care team in a manner consistent with the patient’s treatment plan and medical record.*

  • Facilitates timely and appropriate planned care and services across the continuum, in concert with the patient’s medical treatment plan and healthcare team directives.*

  • Sponsors and facilitates care coordination planning via multidisciplinary teams.*

  • Follows patients across the care and service continuum, as appropriate; works in tandem with cohort of care coordination staff in the ambulatory, acute and post-acute environments as well as community programs that support the patient and care team.*

  • Assists patients in navigating the healthcare system, avoids delays in treatment, readmissions and unplanned care such as emergency room visits and hospital admissions.*

  • Ensures accurate and timely information exchange to eliminate fragmentation, duplication or gaps in health.*

  • Encourages patient engagement and self-management, utilizing motivational interviewing andcoaching.*

  • Proactive as the patient’s advocate, responding and working to resolve issues as soon as possible.*

Stewardship

  • Keeps patients engaged in shared resource decisions.*

  • Understands each patient’s situation, considers available options, and utilizes available patient resources in the most efficient manner.*

  • Works with patients, caregivers and health care teams to avoid unplanned, unnecessary and duplicative care.*

  • Maintains working knowledge of and directs patients to efficient providers and community resources.*

  • Utilizes evidence-based tools and guidelines to reinforce standardization and consistency.*

Outreach

  • Maintains comprehensive and relevant knowledge of healthcare and community services assets(local, regional & state-wide)*

  • Works with patients, families, caregivers and healthcare teams to facilitate planned access to community services.*

  • Conducts outreach and networking efforts to establish and maintain positive working relationships with key community service assets across the continuum.*

  • Home visits may be required at specific entities, uses alternatives for care outside the traditional office setting to increase access to the care team, such as e-visits, phone visits, group visits, hospital visits, home visits, and visits in alternate locations (e.g., senior centers, assisted living centers, skilled nursing facilities and long term care facilities).

Development

  • Seeks out learning opportunities and continuing education to improve care, knowledge and skills.*

  • Seeks experiences that reflect current practice to reinforce and maintain skills and competence in clinical practice or role performance.*

  • Maintains professional records that provide evidence of competency and lifelong learning.*

  • Evaluates one’s own integrity and practice in relation to professional practice standards and guidelines, relevant statutes, rules and regulations; takes action to achieve goals identified during the performance evaluation process.

  • Demonstrates commitment to Centura and Centura Health Neighborhoods as active participant and contributor.

Transformation/Quality Improvement

  • Remains aware of delivery system transformation activities and tenets of Centura Health Neighborhoods and second curve development.

  • Shows willingness to evolve role as system transformation occurs.

  • Shares insights, teaches others, and acts as nominal leader in shaping and influencing value-based care delivery.*

  • Understands the value of measurement and the importance of continuous quality improvement data; uses quality measures to improve performance and accountability for patient outcomes, patient experiences and safe delivery of care.*

  • Participates in evidence-based practice and research activities; uses current healthcare research findings and other evidence to expand clinical knowledge, enhance role performance, and increase knowledge of professional issues.*

Technology

  • Adapts to rapidly changing technology as evidenced by practical competency in technology and related equipment used in the patient care setting.*

  • Uses computers and information technology to document patient care plans and actions, communicate progress to the patient and care team, and support decision-making.*

_Physical Requirements_

  • Sedentary Work - prolonged periods of sitting and exert/lift up to 10 lbs. force occasionally

Important notification to applicants as of Nov. 20, 2014: Effective Jan. 1, 2015, Centura Health will no longer hire tobacco users in Colorado and Kansas. The change to our policy does not apply to associates hired on or before Dec. 31, 2014. Centura Health is an Equal Opportunity Employer, M/F/D/V.