Dignity Health RN Care Coordinator in Redding, California
The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.
Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.
The North State Quality Care Network (NSQCN) is a clinically integrated physician network sponsored by Dignity Health. The RN Care Coordinator is an employee of Dignity Health Management Services Organization.
The goal of care coordination is to assist in managing care, cost, and outcomes throughout the continuum of care: discharge from acute or skilled nursing to home setting. The implementation of sound clinical, fiscal, and operational strategies is critical to the continued delivery of quality services. Care coordination principles provide an opportunity to balance care with cost. The NSQCN care coordination program’s purpose is to promote efficiency, efficacy, and effectiveness of services for patients. The long-term goal of the program is to classify all patients into case management categories (complex, routine, etc.) and assign them to RN care coordinators or social workers, based on acuity and need.
The RN Care Coordinator plans and coordinates all phases of ambulatory care coordination using a problem solving process that includes assessment, problem identification, goal definition, plan development, evaluation to achieve optimum patient outcomes. This position requires a successful track record of interaction with physicians, staff, patients and their families, as well as all aspects of patient care management including referral development, assessment of patient clinical needs, and coordination of the interdisciplinary plan of care.
PRINCIPLES DUTIES AND RESPONSIBILITIES
Concurrently reviews patient records to collect data to carefully understand the needs of the patient by reviewing their background history, understanding their current needs, and arranging for their wellbeing.
Using industry guidelines, assesses appropriateness of hospital admission, level of care, and length of stay.
Completes a comprehensive clinical interview with the patient, family members and/or care giver identifying problems or opportunities that would benefit from care management intervention such as over-utilization or under utilization of services, use of inappropriate services or level of care, non-adherence to plan of care, lack of education or understanding of disease process, language or cultural barriers, current condition(s) or medications, functional limitations, lack of support system or presence of a support system under stress, financial barriers, compromising patient safety.
Documents initial assessment within 48 hrs of patient, family or caregiver contact.
Evaluates patients overall risk using risk stratification tools and determines if meets routine care management or complex care management criteria.
Assesses physical, psychosocial and other needs to ensure individualized care plan captures patient's current healthcare needs, determining when Social Worker intervention is needed.
Reviews medications and recognizes potential medication discrepancies and barriers referring to and coordinating with pharmacist in managing patient medication needs.
Coordinates with other disciplines to facilitate the patient’s individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs.
Assists in development, implementation and revision of individual treatment plans; assures that services provided are specified in the Treatment Plan and monitors progress toward treatment goals, including documentation of daily improvement in patient’s condition or otherwise notes lack of improvement for reassessment of appropriateness of treatment plan.
Communicates with the primary care and specialist physicians, regularly, to evaluate the status of each patient. Collaborates with other team members to ensure appropriate interventions are implemented. These communications will occur as frequently as is needed to ensure care is appropriate according to patient status.
Measures effectiveness and outcomes of the care plan and collaborates with the health care team for quality improvement (primary care physician, social workers, pharmacists, home visit providers, care coordination support staff).
Teaches, coaches and educates the patient, family and/or caregiver about their disease process to recognize signs and symptoms of worsening disease and how to take appropriate measures.
Assesses and makes referrals to appropriate community resources to facilitate patient progression toward expected goals/outcomes.
Has a working knowledge of the financial aspects related to a variety of payer sources.
Reports weekly to the Executive Director regarding patient status and identifies any potential risk management.
Maintains case files and reports.
Other duties as assigned.
EXPERIENCE: Preferred experience in care management in a hospital, nursing home, medical group, or health plan setting.
EDUCATION AND TRAINING: Bachelor Degree in Nursing; Current Registered Nurse License in California.
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Dignity Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected Veteran status or any other characteristic protected by law. For more information about your EEO rights as an applicant, please
If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at (415) 438-5575 and let us know the nature of your request and your contact information. Requests for accommodation will be considered on a case-by-case basis. Please note that only inquiries concerning a request for reasonable accommodation will be responded to from this telephone number.
Job ID 2018-53270
Employment Type Full Time
Department Care Coordination
Hours / Pay Period 80
Facility Dignity Health Management Services Organization
Standard Hours Mon-Fri (8-5 PM)