Care Coordinator RN

At Children’s Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.
Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.
Our dedication to promoting children’s health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:
Utilizing advanced nursing skills and knowledge, the Care Coordinator is responsible and accountable for coordinating care throughout the continuum of care for an assigned patient population. Care Coordination in the hospital and healthcare system is a collaborative practice model. In partnership with the patient, family, and other care givers, the Care Coordinator will work with the multidisciplinary team, Providers, Nurses, Social Workers, financial counselors, and other ancillary staff to actively facilitate those functions associated with moving the patient through the continuum of care. This role will support the continuity of care across the continuum by advocating for the needs of the patient and family and working with identified care team members to promote access to care, facilitate communication and provide effective resource coordination during care transitions to ensure continuity, quality and closure of gaps in care. Identifies and implements initiatives and opportunities to improve processes.:

Responsibilities:

• Responsible and accountable for prescribing, delegating and coordinating patient care. Uses clinical judgment based on nursing skills acquired through formal and informal experiential knowledge and evidence based guidelines to globally assess the patient’s situation and through critical thinking and clinical decision making, develop an appropriate plan of care for the patient, with the aim of promoting best outcomes.
• Accountable that patient care meets standards of safety, effectiveness, patient rights and guest relations.
• Oversees care delivered by patient care team; coordinates plan of care.
• Provides education and facilitates learning for patients, families, and patient care team in a way that demonstrates a sensitivity to recognize, appreciate, and incorporate differences related to diversity.
• Collaborates with physicians, families and other healthcare professionals to assist in developing and implementing an appropriate plan of care in a way that promotes/encourages each person’s contributions towards achieving the best patient outcomes.
• Advocates for the patient, represents the concerns of the patient/family and identifies and assists in resolving ethical and clinical concerns.
• Will deliver care with a team-orientation, an emphasis on good customer relations, sound clinical judgment and appropriate decision-making abilities that take into consideration evidence based practice.
• Continuously inquires about the condition of the patient through the ongoing process of questioning and evaluating the situation and implements treatment changes, if necessary, through collaboration with the health care team, inclusive of the patient and family.
• Maintains a body of knowledge and tools that allow the nurse to manage whatever environmental and system resources exist for the patient/family, within or across healthcare and non-healthcare systems.
• Care Coordination / Disease Management:
• * Completes and analyzes comprehensive assessment with patient intake
• * Treatment plan coordination and management to include payors, supplies and equipment, medications, in-house services, other healthcare facilities and community resources/entities
• * Collaborates with the health care team on the plan of care, referrals and ongoing needs of the patients
• * Ensures consults, testing and procedures are sequenced in a manner that is appropriate to the patient’s clinical condition and supports timely and efficient care delivery. Intervenes, resolves or escalates where barriers to service exist
• * Utilize disease-specific clinical pathways to ensure effective clinical / disease management
• * Assess the educational needs of patients, families, and caregivers taking into consideration barriers to care (e.g., literacy, language, cultural influences, comorbidities)
• * Ensure that education regarding the clinical / disease process has been provided by the health care team
• * Coach patients/families toward lifestyle changes and successful self-management of their chronic disease
• * Demonstrate customer-focused interpersonal skills, utilizing problem-solving processes and critical thinking
• * Facilitates communication and coordination of the plan of care with the Providers and the health care team
• * Involvement in the development of strategies and plans to maximize the most appropriate use of services in the assigned areas
• Resource Management:
• * After considering the relevant, evidence-based clinical information, support and advise patients, families and the organization in the care options that are most cost-effective
• * Navigate payor benefits and assist patients and families in understanding insurance plan benefits and financial impact with transition management and discharge planning
• * Understand impact on the organization and utilize knowledge of Diagnosis Related Groupings and estimated length of stay as guides when developing discharge plans
• * Understand the negative impact of readmissions on the patient and the health care system, and engage in review of root cause and implementing strategies to prevent readmission
• Discharge Planning / Transition Management:
• * Identifies and addresses actual and potential barriers in service or treatment and works with the appropriate resources across the continuum of care
• * Evaluates with the team, the patient’s response to pharmacological and therapeutic treatment regimens
• * Works with multidisciplinary staff to ensure patient / family has received appropriate information and education prior to transition to the next level of care
• * Identify and solve problems related to discharge needs; implement a plan of care and coordinate a safe and timely discharge
• * Ensure / maintain plan consensus from patient / family, healthcare team and payor
• * Advocate, mediate and negotiate to formulate a cohesive plan for maintaining or enhancing patient’s health status and moving the patient safely to the next level of care
• Communication:
• * Communicate and resolve conflicts with Providers, health care team members, community agencies, clients and families with diverse opinions, values, and religious/cultural ideals
• * Build therapeutic and trusting relationships with patients, families and caregivers through effective communication and listening skills
• * Continually communicate with patients and families, Providers, multidisciplinary team members and payors to facilitate coordination of clinical activities and to enhance the effect of a seamless transition from one level of care to another across the continuum
• Managing Key Performance Indicators (as defined by the hiring manager):
• * Works to improve quality through reduction in treatment delays, use of clinical pathways and monitoring of quality indicators
• * Provide ongoing consultation and training to medical staff and other healthcare professionals on discharge and home care issues; participate in process improvement activities; identify barriers in service delivery systems and develop a process for improvement
• * Increase quality, efficiency and patient satisfaction while managing cost of care for targeted population
• * Collects, completes and submits statistical data in a timely manner
• Professional Development:
• * Remain current in EMTALA and regulatory requirements
• * Stay abreast of payor guidelines and standards
• * Stay abreast of community resources available to facilitate safe patient transitions of care
• * Remain current on clinical advancements related to primary patient population
• * Proactively seek to understand areas/roles outside of immediate area/role within the department
• Community involvement and advocacy: participates in health fairs, appropriate professional organizations and educational speaking

Other information:
WORK EXPERIENCE

• At least 4 years Pediatric nursing, Case Management, Care Management, Care Coordination, Utilization Review, or Community-based nursing required

EDUCATION

• Two-year Associate’s degree or equivalent experience required
• Four-year Bachelor’s degree or equivalent experience preferred
• Care Coordinators must have a minimum of a BSN by December 31, 2023. Effective 10/1/2020, new employees in this position must have a BSN at time of hire required

LICENSES AND CERTIFICATIONS

• Registered Nurse in the State of Texas Upon Hire required
• Accredited Case Manager (ACM) or Certified Case Manager (CCM) or Care Coordination and Transition Management (CCTM)
• Upon Hire preferred
• Effective 7/1/2023, Basic Life Support for Healthcare Providers as required by CP 1.20 Life Support Course Requirements required