RN Care Coordinator – Asthma

A caregiver in this position works days Monday – Friday from 8

• 00 a.m. – 5:00 p.m. with the opportunity to work from home one day a week.
• A caregiver who excels in this role will: Work collaboratively with a multidisciplinary care team across the continuum of care for high-risk patients to develop goals, plan interventions and maximize patient outcomes. Outlines the nature and duration of involvement needed by the specialty care team and specialty care coordinator then identifies the primary care team involved. Utilize technological tools (registries, patient lists, care team tab, etc.) to manage population Use assessment skills and tools to identify patients with actual or potential care needs that would require care coordination. Conducts targeted outreach to a defined panel of high risk patients (chronic illness, lack of social support, readmissions, ED visits, surgical episodes, etc.) to ensure timely and efficient care delivery across the continuum of care. Provide care and disease management coordination. Identify patients in the specialty care practice that have ongoing coordination needs and conduct targeted outreach. Conduct comprehensive clinical assessments that include disease/age-specific, medical, behavioral, pharmacy, social and end of life needs of each patient. Inform and work with patients and their families regarding coordination of their care, provide education and coaching, monitor patient compliance with their care plan, perform reassessments regarding patient progress toward goals, and update plan of care. Serve as a liaison and advocate for patients and families. Assist in managing transitions of care across care settings, ensuring optimal communication and planning. Identify barriers, facilitate solutions, and connect others to community resources. Define and ensure compliance with disease-specific care paths for specialty care or chronic disease. Work with the patients and family to assess current knowledge, health literacy, and readiness to change, utilizing teach back to assess level of knowledge. Coach patient and family on self-management support; including setting long and short term goals. Educate about managing a specialty or surgical condition (inclusive of preoperative, perioperative, postoperative and recovery) inclusive of prevention and health maintenance tasks. Work with practices on quality and process improvement initiatives.
• Minimum qualifications for the ideal future caregiver include: Graduate from an accredited school of Professional Nursing Current state licensure as a Registered Nurse (RN) Basic Life Support (BLS) Certification through the American Heart Association (AHA) or American Red Cross Three to five years of nursing experience Strong attention to detail and therapeutic communication skills
• Preferred qualifications for the ideal future caregiver include:
• Bachelor’s of
• Science in
• Nursing (BSN)
• Physical
• Requirements: Requires full range of motion, manual and finger dexterity and eye-hand coordination. Requires corrected hearing and vision to normal range. May requires some exposure to communicable diseases or bodily fluids. Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Even though the weight lifted may be only a negligible amount, a job should be rated