Core - Nurse Care Coordinator

Company Name:
Exeter Hospital
The Care Coordinator will work as an embedded member of the health care team in an assigned location collaborating with site physcians and staff. Responsible for facilitating collaboration, communication, and care coordination with all members of the healthcare team to support the patient across the health care continuum. Responsible to assess, plan, implement and evaluate comprehensive, coordinated health services for the high risk identified patient population to support their achievement of the highest level of self-management. Also responsible for working with teams and leadership to: design, develop and implement care management standard work as well as evaluate performance & outcomes.
Bachelor's degree in related field or equivalent experience
3-5 years Care Management, Care Coordination, or Case Management experience
Registered Nurse- N.H. State or valid nursing license in another compact state

Major Responsibilities:
1. Serves as the liaison with assigned patients & families to physicians and clinical staff involved in the care of the patients. Advocates for the patient and families, responds to and facilitates resolution of patient questions and concerns. Provides or arranges needed patient education regarding specific health care skills and general disease concepts.
2. Conducts comprehensive clinical assessments that include the age-specific, medical, behavioral, pharmacy and social needs of each assigned patient. Shares this information with the healthcare team and with the patients. Uses this information to develop and maintain a customized, patient-specific care plan incorporating the patient and family in the development of the plan. Documents necessary patient care management within the EHR and assists in developing tools for efficient, effective care management and care plans.
3. Partners with patients and families on self management support including: a. Sets short and long-term goals for self-management of chronic disease to include acute exacerbation management. b. Performs reassement in patient progress toward goals, assesses barriers and alters plan of care as appropriate.
4. May assist other members of the health care team with identifying patients overdue for visits, labs, in need of referrals or admitted to ED, inpatient, sub-acute facilities or VNA and arranges for follow up as appropriate.
5. May assist other members of the health care team to optimize patient experience with provider visits by assisting with pre-chart review for required preventative health maintenance needs, chronic disease interventions, necessary forms etc.
6. Utilizes disease registry database, updating as necessary, monitoring quality reporting from registry. Develops standard work around use of disease registries and the role of various team members in registry management. Determines what if any of this work can be centralized.
7. Works with Practice Managers to insure that all appropriate members of the health care team are regularly monitoring registries for gaps in care as part of pre and post visit planning.
8. Participates in quality improvement projects aimed to improve patient-population outcomes and associated processes both within Core Physicians and across the healthcare system/affiliates.
9. Helps design a plan for roll-out of these functions across the designated practices.
10. Mentors and coaches clinical staff within the practices as we roll out the care management role across Core.

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