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RN Coordinator- At Home Care- Hybrid- Philadelphia, PA ID-6326

About the position

The RN Coordinator serves as the key contact point for the patient to coordinate and streamline all services offered within Evernorth Health Services. This role is essential in educating patients on healthcare options, providing patient education, and answering questions as they arise. The patient navigator must be compassionate and positive, inspiring confidence in the patients they work with. They will work closely with patients, other staff, and providers to address any inquiries regarding schedules, appointments, orders, consults, and more. The RN Coordinator is responsible for knowing where to find all member information and directing and delegating tasks to team members as needed. In addition to being the point of contact for all aspects of the member's appointments, care, and overall health, the RN Coordinator acts as a liaison between providers and their patient panel. They will educate patients about their care options and make specific recommendations based on individual goals. The role involves reviewing paperwork to ensure it meets all requirements, explaining test results, diagnoses, and other medical outcomes, and covering any additional triage and transition of care for patients as needed. The RN Coordinator also plays a vital role in improving health literacy by coaching patients on chronic conditions, medication education, and individualized care goals management in a culturally sensitive manner. They will identify problems or gaps in care and offer opportunities for intervention, coordinate services and referrals to health programs, and participate in patient education and outreach tied to HEDIS initiatives. The RN Coordinator works to improve access to care and collaborates with the team to manage healthcare costs and utilization. Furthermore, the RN Coordinator completes telephonic nursing assessments, assists with organizing chronic care and interdisciplinary care team rounds, and participates in creating care plans for patients. They maintain and update spreadsheets and documents provided by the health plan to prepare for weekly rounds of documentation. The role also includes managing post-acute care coordination, referral management, and diagnostics and lab result management, ensuring timely and accurate follow-up on patient care.

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Responsibilities

  • Be the point of contact for all aspects of the member in regard to their appointments, care, and overall health.
  • Act as the liaison between the providers and their patient panel, directing and delegating tasks to team members.
  • Educate patients about their care options and make specific recommendations based on their goals.
  • Review paperwork for patients to ensure it meets all requirements.
  • Explain test results, diagnoses and other medical outcomes.
  • Cover any additional triage and transition of care for patients as needed.
  • Improve health literacy and coach patients on chronic conditions including disease process and trajectory, medication education including possible side effects, plan of care, and individualized care goals management.
  • Identify problems or gaps in care and offer opportunity for intervention.
  • Coordinate services and referrals to health programs and participate in patient education and outreach tied to HEDIS initiatives.
  • Work to improve access to care and manage healthcare costs and utilization.
  • Complete telephonic nursing assessments including social determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider.
  • Assist with organizing and running chronic care and/or interdisciplinary care team rounds where high risk patients and care plans are identified.
  • Participate using a team approach to create a care plan for the patient.
  • Maintain and update spreadsheets and documents provided by health plan to prep weekly rounds of documentation.
  • Participate in weekly care coordination with health plan case management as directed by market needs.
  • Manage referral coordination and tracking of hospice consults within 24 hrs. of order placement.
  • Obtain Pre Authorization for all CT, MRI, Echo's ordered by providers.
  • Serve as a guide in their POD for all escalated orders and results as clinically appropriate.
  • Assess and triage immediate health concerns transferred to nursing team by clinical support staff.
  • Provide telephonic nursing assessment and triage supported by triage protocols.
  • Initiate medication changes and other orders, as directed by provider in response to a triage call.
  • Monitor daily discharge list and develop a plan to schedule transition of care visits within the allotted timeframe.
  • Complete telephonic post-discharge hospital visits and ask pertinent discharge triage questions and complete medication reconciliation.
  • Document all findings and make appropriate referrals to social work, pharmacy, case management and engagement.

Requirements

  • Active, unrestricted RN license in all states we provide services.
  • Ability to obtain compact license and/or additional state licensure as needed.
  • 3+ years of experience as a Registered Nurse.
  • Proficient level of experience with Microsoft Office applications, and strong technical aptitude.
  • EMR experience and proficiency.
  • BSN or ADN degree.

Nice-to-haves

  • Previous experience working with the geriatric population/ chronic condition experience.
  • Home Health experience.
  • Triage experience.
  • Case management experience.
  • Previous customer service experience.
  • Previous experience in a telephonic role.
  • Highly organized, self-directed worker with an ability to function in high volume environment.
  • Strong verbal and written communication skills.
  • Prior clinical experience in palliative care, end of life, hospice, oncology, ICU, geriatrics is preferred.
  • Knowledge of STARS and Hedis metrics a plus.

Benefits

  • Smoking cessation program
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