RN-Care Coordinator-Ambulatory-Ambulatory Patient Advance Access

Job Objective:

Responsible for coordinating patient-centered care across the outpatient continuum, with a focus on high-risk and complex patient populations. Collaborates closely with providers, interdisciplinary teams, and community resources to support high-risk and complex patients through proactive outreach, comprehensive assessment, care planning, and transition management. Aims to improve clinical outcomes, enhance patient experience, and reduce unnecessary utilization.

Essential Responsibilities:

• Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
• Establishes rapport and a relationship with the patient and family in order to understand their needs and expectations and to assist them in setting realistic and mutual goals; integrates an awareness of cultural factors in the patient/family interview process and elicits clinically relevant cultural information.
•  Collaborates with the physician, patient and interdisciplinary team to establish a comprehensive plan of care to appropriately address clinical milestones.
•  Communicates plan of care, including changes and issues related to plan of care to patient/family, physicians and other members of the healthcare team; facilitates communication between the physician, interdisciplinary team, patient and family.
•  Gathers sufficient information from all relevant sources to determine the effectiveness of the plan of care to assure it is done in an accurate, safe, timely and cost-effective manner.
•  Organizes, integrates and evaluates the effectiveness of the plan of care and progress toward achievement of desired outcomes; modifies plan of care as patient/family needs change to accomplish goals established in the plan of care.
• Identifies and facilitates resolution of clinical and operational roadblocks to achieve optimal outcomes by identifying alternatives as needed; communicates resulting decisions to patient/family, physicians and members of healthcare team, according to regulatory guidelines and hospital policies.
• Identifies opportunities to improve care/service; assists in development and implementation of care performance improvement plans based upon analysis of patterns and trends identified from data collection and observations.
• Documents all care management assessments and interventions.
• Ensures that the care plan is updated as appropriate, through clinical progression of the patient toward clinical milestones updating the team and patient and family accordingly.
• Refers to Social Worker or Discharge Planner for complex psychosocial and discharge planning issues (per criteria) and ensures appropriate follow-up; consults with other members of the interdisciplinary team (physical therapy, pharmacy, etc.) to provide safe discharge as appropriate.
• Ensures that any information appropriate to facilitate continuity of care post discharge is communicated to post-acute provider via discharge paperwork or via phone per departmental documentation guidelines.
• Develops strong relationships with community health resources; develops, maintains and provides community resource information to patients.
• Helps patients obtain a PCP (Primary Care Physician) and affordable discharge medications and resources as necessary.
• Ensures appropriate follow-up appointments are made and patient is knowledgeable about post discharge activities.
• Monitors and manages clinical outcomes and intervenes on issues that have the potential to impact quality.
• Performs proactive outreach to high-risk patients, including those with frequent ED visits, hospitalizations, or chronic conditions.
• Coordinates transitions of care (e.g., post-ED, post-inpatient, SNF discharges) to ensure timely follow-up and prevent readmissions.
• Collaborates with primary care providers, specialists, and interdisciplinary teams to align care plans and close care gaps.
• Facilitates referrals to internal programs (e.g., social services, behavioral health, pharmacy support) and external community resources.
• Educates patients and caregivers on disease management, medication adherence, and navigating the healthcare system.
• Identifies and escalates clinical concerns or barriers to care to appropriate providers or leadership.
• Participates in interdisciplinary case conferences, team huddles, and quality committees.
• Utilizes data, registries, and dashboards to prioritize outreach and measure effectiveness of interventions.
• Assists with advance care planning discussions and long-term care planning when appropriate.
• Embraces professional governance philosophy and demonstrates support through active participation and engagement.
• Performs other duties as assigned.

Essential Skils:

• Written and verbal communication skills
• Knowledgeable about the various health care delivery systems and payer prior approval requirements
• Strong clinical and critical thinking skills and ability to establish and carry out complex plans of care for key diagnoses
• Knowledgeable about regulations, standards and legislation (local, state and federal) related to the continuum of care and patient transition
• Self-motivated, self-starter, and able to organize efforts around helping clients have a positive experience
• Knowledgeable about notices of non-coverage/denial letters to patients including Medicare/HSAG, federal and state and guidelines
• Ability to work independently and exercises a high degree of initiative, judgment and discretion
• Ability to communicate with patients, healthcare professionals, and staff to ensure clear and accurate exchange of information
• Ability to analyze situations accurately and takes effective action