Centura Health connects individuals, families and neighborhoods across Colorado and western Kansas with more than 21,000 of the most talented hearts and minds in medicine.
Through Centura Health’s 17 hospitals, two senior living communities, health neighborhoods, physician clinics, Flight for Life® Colorado, home care and hospice services, we offer a diverse range of work settings in a Colorado or Kansas community you will love to call home.
Enjoy amazing people, competitive pay, some of the best benefits in the industry and plenty of opportunity for professional growth and development.
If you’re ready to discover the difference of working for a fully-integrated health system with a non-profit, faith-based mission to care, we look forward to receiving your application.
Job Description/Job Posting ID: 134172
Recruiter Contact: CharlieHoshall@centura.org
Schedule: Full Time
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
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
Current Colorado RN license in good standing
Position Duties (essential functions denoted with an * )
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.*
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 and coaching.*
Proactive as the patient's advocate, responding and working to resolve issues as soon as possible.*
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.*
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).
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.
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.*
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.*
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.
Find your ideal career at Centura Health! With 16 hospitals, physician clinics, hospice services, home care and senior living communities, Centura Health's vast network of care spans Colorado and Western Kansas so you can experience a balanced lifestyle and enjoy a fulfilling career anywhere you want to work, live and play in Colorado. From the fast pace of a Denver-area Level 1 Trauma Center to a smaller rural or mountain hospital – we proudly offer a more diverse range of work settings and locations than any other health care employer in the state. Centura is an equal opportunity employer.