Summary: The RN Care Coordinator functions as an extension of the provider and positively impacts the patient's quality of care and ability to access care, reduces unnecessary costs and generates revenue. Key functions include building relationships with patients, functioning as a team member in the practice and the patient's continuum of care, increasing patient experience, performing annual Medicare wellness exams, mitigating hospital readmissions, closing care gaps, and identifying social determinant of health barriers that impact the patient's ability to maintain optimal health and wellness.
3-5 years of experience working as an RN and also experience working in care coordination, care management or case management.
RN license in the state of Delaware or compact state
Primary Care or physician office experience preferred.Experience performing annual well visits desirable.
Improve quality by closing care gaps a. Medicare annual wellness exam b. Breast cancer screening c. A1C >9 d. HTN <140 f. Increasing h. Depression to 3. 90 patients care access screening Fall Increase style="font-family:Arial;" PCP resources: Colorectal see risk a. additional e. g. admissions healthcare and 2. costs nephropathy of unnecessary hospital time utilization by preventing Reduce Diabetic>e. Fall risk screening f. Depression screening g. Diabetic nephropathy screening h. Colorectal screening 2. Increase access to care by a. Increasing PCP time to see additional patients 3. Reduce costs by preventing hospital admissions and unnecessary utilization of healthcare resources: a. Ensure TCM calls and visits are completed for post-hospital patients. i. Address social determinant of health barriers 1.Transportation to/from appointments and for necessities (groceries, pharmacy, etc.) 2. Ability to obtain and afford medications ii. Self-management of reason for being in hospital and chronic conditions iii. Address behavioral health needs b. Care-manage high-risk patients with chronic conditions and high RAF scores: COPD, CHF, Diabetes, HTN, and increased acute care and ED utilization 4. Generate additional revenue a. Identification of and scheduling problem office visits (following MAWE or separate visit) b. Ensure bi-annual visits with PCP c. Ensure optimized visit scheduling for managing chronic conditions 5. Employee/Provider Engagement a. Demonstrate effective communication, collaboration, and team-based mentality b. Demonstrate ability to build relationships with patients c. Function as a team member within the practice d. Communicate with providers/clinical team about daily patient schedule e. Participate in daily huddles/team meetings. Other duties as assigned.
Competencies and skills: Essential: * Clear Communication Skills Both Written And Verbal * Able To Keep Confidential Information Regarding Patients, Team Members * Able To Withstand Crisis Situations * Has Skills To Provides Customer Service To Patients, Team Members And Visitors * Knowledge And Experience With Electronic Health Records
Education: Essential: * Associates Degree in related field Education specialization: Essential: * Nursing
Education equivalent experience: Essential: * OR SOCIAL WORK OR BUSINESS
Beebe Healthcare serves the Sussex County community with a medical center located in beautiful, historic Lewes, Delaware, and convenient outpatient locations throughout the county. Founded in 1916 by two physician brothers, Drs. James Beebe and Richard C. Beebe, the medical center in Lewes is a 210-licensed-bed, not-for-profit seaside community hospital. Beebe's specialized service lines include cardiac and vascular, surgical services, oncology, women's health, and orthopaedic services. Beebe offers an array of inpatient, outpatient, emergency, and diagnostic services.
Beebe's five satellite campuses offer imaging, physical rehabilitation, and lab services, as well as walk-in care centers. In addition, Beebe offers Wound Healing & Hyperbaric Medicine and Diabetes Management & Medical Nutrition Therapy.
With a mission to serve the community, Beebe also offers many free screenings and outreach programs through its Population Health Department; and advanced medical care for those who are recuperating at home through Beebe Home Care Services.
Beebe is also training the next generation of nurses through the Margaret H. Rollins School of Nursing, located behind the Medical Cente...r in Lewes.
Beebe's Medical Staff has grown tremendously since the early 1990s. Employed physicians through Beebe Medical Group and our affiliated physicians on Beebe's Medical Staff now serve patients from Milford to Millville in specialties including cardiac surgery, dermatology, endocrinology, family practice, gastroenterology, general surgery, internal medicine, pediatric neurology, and surgical oncology.
Beebe is proud to offer quality care, close to home for the residents and visitors of Sussex County.