Dartmouth-Hitchcock
Performance Network Operations Care Coordinator – RN, Full-time
Dartmouth-Hitchcock, Manchester, New Hampshire, us, 03103
Overview
Identifies opportunities for the D-H attributed patients in our risk contracts to improve the health and reduce cost for that patient population. Provides health screening, assesses social determinants of health, and participates in care management and transitional care management to improve clinical quality. Functions as a resource to patients and families, partners with primary care, and is a conduit to D-H payer contracts to provide comprehensive patient-family centric care with a focus on improving D-H status in risk contracts.
Responsibilities
Manages and coordinates clinical care of defined populations with identified preventative care and/or chronic disease needs.
Identifies and assesses chronic disease patients. Performs a focused nursing assessment to include health and disease management, functional status, cognitive/mental status, nutritional status, available support system, cultural requirements, spiritual needs, identify psycho-social-financial concerns and assesses environmental limits and strengths. Identifies patients/families at high risk requiring on-going coordination of care. Facilitates the development of a comprehensive interdisciplinary disease management plan of care, with the patient, family and all members of the medical home team. Assesses unmet needs, strengths and assets of patients and their families.
Participates in the development of disease management strategies for the ACO and identifies appropriate measures for the evaluation of outcomes. Determines potential focus for groups of patients using available data and tools.
Contributes to the development and maintenance of a care delivery system which is patient/family centered and promotes effective resource utilization.
Assists in collecting and evaluating clinical and financial data/outcomes including patient satisfaction, health and functional status, resource utilization, cost and role effectiveness. Identifies and recommends opportunities for improvement in the system. Leads or participates in quality improvement projects for the practice, especially related to the management of patients with chronic illness. Participates in case conferencing in conjunction with peers and the clinical team. Assists in the development of department annual goals and the identification of outcomes for continuous quality improvement.
Determines eligibility for coaching intervention and determines need for supportive services and makes appropriate referrals.
Acts as a patient advocate utilizing the essential activities of case management: assessment, planning, implementation, coordination, monitoring and evaluation.
Establishes collaborative partnerships with patients and families to assist them in examining patterns of their health care needs and decisions, lifestyle choices, and utilization of resources that affect their health.
Performs comprehensive assessment of patient situation and functioning to identify individual needs in order to develop a plan of care that will address those needs. Identifies actual or potential obstacles to discharge goals and report these to healthcare team.
Assists with coordination of services through the continuum of care that balances the delivery of quality care with the cost effective utilization of resources. Executes activities and/or interventions that will accomplish the case management plans.
Reviews discharge instructions with patient and family and identifies ongoing education needs that exist.
Performs other duties as required or assigned.
Qualifications
Graduate from an accredited Nursing Program required.
Bachelor of Science Degree in Nursing (BSN) and 3 years of clinical experience including 2 years of recent experience in ambulatory care or Care Coordination required.
Excellent assessment, communication, interpersonal, and organizational/time management skills.
Demonstrated ability to work well as a member of a team and respond calmly and effectively in a fast paced environment.
Excellent verbal and written communication skills.
Sound decision making, judgment, time management and negotiating skills.
Familiarity with electronic medical records, and computer applications including MS Word and Excel.
Must demonstrate passion for care of patients with chronic disease.
Knowledge of methods to educate and counsel patients, assess their readiness for changing health behaviors.
Required Licensure/Certifications
Licensed Registered Nurse with New Hampshire eligibility.
Basic Life Support (BLS) Certificate required.
Additional Information
Remote:
Fully Remote;
Area of Interest:
Nursing;
FTE/Hours per pay period:
1.00 – 1.00 – 40 hrs/week;
Shift:
Day;
Job ID:
25573;
Dartmouth Health is an Affirmative Action and Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.
Apply for this Position
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Identifies opportunities for the D-H attributed patients in our risk contracts to improve the health and reduce cost for that patient population. Provides health screening, assesses social determinants of health, and participates in care management and transitional care management to improve clinical quality. Functions as a resource to patients and families, partners with primary care, and is a conduit to D-H payer contracts to provide comprehensive patient-family centric care with a focus on improving D-H status in risk contracts.
Responsibilities
Manages and coordinates clinical care of defined populations with identified preventative care and/or chronic disease needs.
Identifies and assesses chronic disease patients. Performs a focused nursing assessment to include health and disease management, functional status, cognitive/mental status, nutritional status, available support system, cultural requirements, spiritual needs, identify psycho-social-financial concerns and assesses environmental limits and strengths. Identifies patients/families at high risk requiring on-going coordination of care. Facilitates the development of a comprehensive interdisciplinary disease management plan of care, with the patient, family and all members of the medical home team. Assesses unmet needs, strengths and assets of patients and their families.
Participates in the development of disease management strategies for the ACO and identifies appropriate measures for the evaluation of outcomes. Determines potential focus for groups of patients using available data and tools.
Contributes to the development and maintenance of a care delivery system which is patient/family centered and promotes effective resource utilization.
Assists in collecting and evaluating clinical and financial data/outcomes including patient satisfaction, health and functional status, resource utilization, cost and role effectiveness. Identifies and recommends opportunities for improvement in the system. Leads or participates in quality improvement projects for the practice, especially related to the management of patients with chronic illness. Participates in case conferencing in conjunction with peers and the clinical team. Assists in the development of department annual goals and the identification of outcomes for continuous quality improvement.
Determines eligibility for coaching intervention and determines need for supportive services and makes appropriate referrals.
Acts as a patient advocate utilizing the essential activities of case management: assessment, planning, implementation, coordination, monitoring and evaluation.
Establishes collaborative partnerships with patients and families to assist them in examining patterns of their health care needs and decisions, lifestyle choices, and utilization of resources that affect their health.
Performs comprehensive assessment of patient situation and functioning to identify individual needs in order to develop a plan of care that will address those needs. Identifies actual or potential obstacles to discharge goals and report these to healthcare team.
Assists with coordination of services through the continuum of care that balances the delivery of quality care with the cost effective utilization of resources. Executes activities and/or interventions that will accomplish the case management plans.
Reviews discharge instructions with patient and family and identifies ongoing education needs that exist.
Performs other duties as required or assigned.
Qualifications
Graduate from an accredited Nursing Program required.
Bachelor of Science Degree in Nursing (BSN) and 3 years of clinical experience including 2 years of recent experience in ambulatory care or Care Coordination required.
Excellent assessment, communication, interpersonal, and organizational/time management skills.
Demonstrated ability to work well as a member of a team and respond calmly and effectively in a fast paced environment.
Excellent verbal and written communication skills.
Sound decision making, judgment, time management and negotiating skills.
Familiarity with electronic medical records, and computer applications including MS Word and Excel.
Must demonstrate passion for care of patients with chronic disease.
Knowledge of methods to educate and counsel patients, assess their readiness for changing health behaviors.
Required Licensure/Certifications
Licensed Registered Nurse with New Hampshire eligibility.
Basic Life Support (BLS) Certificate required.
Additional Information
Remote:
Fully Remote;
Area of Interest:
Nursing;
FTE/Hours per pay period:
1.00 – 1.00 – 40 hrs/week;
Shift:
Day;
Job ID:
25573;
Dartmouth Health is an Affirmative Action and Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.
Apply for this Position
#J-18808-Ljbffr