Job Description

The Nurse Care Coordinator organizes team-based care planning to provide support and comprehensive health services to individuals, mainly focusing on individuals with higher risk and complex needs, through effective partnerships with patients, their caregivers/families, community resources, and their healthcare providers. Performs short term transitional care activities and longer-term care planning for complex patients through facilitation of a shared care plan across the continuum of care to achieve well-coordinated, timely, cost effective, high-quality care that is patient and family centered.

Primary Duties and Responsibilities

• Manages a panel of active patients requiring complex care management and care coordination support

• Collaborates with the multidisciplinary team, including the patient and their family, to design and implement holistic individualized plans of care for patients enrolled in care coordination programs

• Assess patient and family’s unmet health and social needs as well as health literacy and identifies strategies to resolve needs

• Assesses and identifies strategies to improve the health literacy of the patient and their family/ home care givers as appropriate

• Promotes patient engagement in self-care management through use of strategies such as creating patient directed care plans and motivational interviewing

• Provides chronic disease self-management support and education for patient enrolled in care coordination programs. Educate patients and their home care givers on self-management activities, medications, community resources, and advanced care planning

• Monitors patients’ adherence to plan of care and progress towards mutual goals in a timely fashion, facilitate changes and creates action plans as needed

• Addresses and works to resolve patient concerns or barriers to achieving personal health goals through health coaching, education and coordination of patient access to community resources, financial assistance, and other supports as appropriate

• Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time

• Facilitate patient access to appropriate medical, specialty providers, and community providers

Position Qualifications

Education: Graduate of an accredited nursing program required. BSN or higher-level degree in nursing preferred.

Licensure/Certifications: Current nursing licensure in the state of New Hampshire required. Registered Nurse Licensure in Massachusetts in addition to New Hampshire preferred. Specialty Certification i.e. ambulatory nursing, CCM, CCTM, Guided care, CHCQM preferred.

Experience:

• 5 or more years nursing experience in acute, skilled nursing, community health and/or ambulatory setting required.

• 3 or more years’ experience in care coordination or case manager role in acute, skilled nursing, community health, and/or ambulatory setting preferred.

• Experience working with an ACO or value-based contracts preferred.

What Elliot Health System Has to Offer

• Health, dental, prescription, and vision coverage for full-time & part-time employees

• Short-term disability, long-term disability, and life insurance coverage

• Competitive pay

• Tuition Reimbursement

• 403(b) Retirement Savings Plan

And more !

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