As our Continuing Care RN Coordinator, you will be a central figure in patient care, seamlessly navigating the healthcare journey to achieve optimal outcomes and an exceptional patient experience.

Every day, you will strategically assess, plan, and facilitate comprehensive care across the continuum, expertly advocating for patients while collaborating with physicians, nursing, departments, insurers, and post-acute providers to ensure timely, high-quality transitions.

To be successful in this role, you will possess strong clinical acumen, exceptional communication and advocacy skills, and a strategic mindset, all driven by a passion for optimizing patient care across every touchpoint.

As a remote employee, we will provide you with the equipment needed to work from home, including a laptop, docking station, dual monitors, and accessories.

This position is work from home for residents of CA.

Future potential for occasional weekend/holiday coverage.

• Works with “at risk” patients and families on self-management support, including collaborating with patients to create a plan of care for health behavior change.
• Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program, facilitating collaboration, communication and coordination among all responsible parties of the multidisciplinary healthcare team striving to eliminate fragmentation, duplication or gaps in care.
• Designs plans for data gathering and analysis of baseline, and ongoing assessment of success throughout the project; provides ongoing support to practitioners in collecting, interpreting, and communication data, and developing action plans accordingly. Works toward reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.
• Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible.
• May also be required to meet patients and or family members either in the community, at home, or other location. Must be able to assess the environment for safety for self and patients and escalate any concerns to the Medical Social Worker, Licensed Social Worker or program manager based on the situation.

Required

• Two (2) years relevant experience or advanced degree
• Associates degree in Nursing
• Clear and current CA Registered Nurse (RN) license
• Manages and works closely with interdisciplinary partners in the management of identified patient populations. Oversees a mix of clinical, operational, and business activities related to that team.
• Implements specific program goals including high priority case management redesign efforts required to improve performance.
• Works closely with and in partnership with Community resource partners, Post Acute Care Providers, Acute Care Coordinators and other clinical staff who are focused on care coordination in order to ensure that patients' care and transition of care from acute care to post-acute and ambulatory care are seamless.
• Assesses, reports, and communicates patient status on a periodic basis to all team stakeholders
• Excellent computer skills and ability to learn new systems
• Strong organizational (time management) and interpersonal skills
• Ability to handle multiple priorities with strong attention to detail
• Ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word.
• Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost)
• Ability to work autonomously within a matrix environment without direct supervision or support

Preferred

• Bachelors of Nursing (BSN) preferred
• 5+ years of care coordination experience preferred
• Experience with telephonic care coordination preferred
• Experience with motivational interviewing and effective telephonic engagement with patients preferred
• Bi-lingual preferred