RN - Care Coordination

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

7/1/2022

Entity:

Wisconsin

Job Code:

800058

Job Title:

RN - Care Coordination

FLSA Exemption Status:

Non-Exempt

Management Level:

Individual Contributor

JOB SUMMARY

RN Care Coordination (RNCC) is a collaborative process meets an individual and family's comprehensive health needs through communication and utilization of available internal and external resources to promote quality cost-effective outcomes.  The RN-Care Coordination needs well developed knowledge and skills in the assessment, evaluation and interventions of persons and families with multiple and/or complex care needs.  Organizational skills are of utmost importance to prioritize clinical issues and manage a caseload of a large number of patients with varying degree of health and psycho-social needs.

The RN-Care Coordination will develop individualized care plans in collaboration with other resources and personnel, including but not limited primary care physicians and care team, Transitions of Care, Patient Resources, Complex Case Management, Emergency Departments and Urgent Care to provide consistent goal directed care.   The RN-Care Coordination will provide comprehensive care, including chronic disease management and medication titration, within established protocols. 

ESSENTIAL DUTIES

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Conducts a comprehensive patient and support system assessment at initial visit and at intervals necessary to update goals and plan of care.

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Comprehensive review of patient health record, external health records, health status and risk factors.

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Identifies family and support system strengths and needs.

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Use multiple modalities for communication including face to face visits, written communication (MyChart) and telehealth such as telephone encounters or video visits.

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Identify patients for care coordination using various tools such as Multi-Condition Reporting Workbench.

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Promote patient autonomy and self-management of conditions

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Assist with safe transitioning of care to most appropriate level of care

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Terminate care coordination when client reaches most appropriate level of care

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Utilizes data and metrics to meet patient and organizational needs.

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Maintains high level of skill and responsibility, including but not limited to:
o Symptom management
o Review and act on test results
o Review and manage communications
o Initiate and monitor intravenous (IV) infusions
o Assist or perform procedures (e.g. ECGs, dressing changes, injections)
o Patient education
o Execute delegation protocols
o Assist with medication management
o Complete accurate and timely documentation in the electronic medical record
o Assist with management of urgent and emergent patient care situations
o Serve as a mentor and resource to others
o Motivational Interviewing

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Coordinates and facilitate patient care and progression through the care continuum (e.g. recognizing need for assisted living and working with physician and patient to support patient)

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Continuously monitors patient’s progress, intervening as necessary to ensure high quality care and services

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Meets with patients and families to assess needs and develop individualized care plan, collaborating with interdisciplinary team, including care team members outside UW Health

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Initiates and/or facilitates referrals to other resources or agencies, e.g. skilled nursing facility, assisted care, Patient Resources.

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Clinical consultation with primary care physician and care team, internal and external care team members. Responds to all requests appropriately and within a timely manner. Seeks consultation from appropriate disciplines/departments as needed.

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Refers appropriate patients to other services, e.g. Dietician, Certified Diabetic Educator, Behavioral Health

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Participates in clinical improvement activities.

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Uses data for decision making and performance improvement

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Assists with data collection and resource utilization for outcome measures

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Use quality tools and processes to develop or support quality improvement projects

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Demonstrates positive and professional written and professional verbal and non-verbal communication

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Utilizes motivational interviewing to facilitate patient and family centered goal setting

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Apply critical and analytical reasoning and astute clinical judgement in order to expedite appropriate health care in order to coordinate appropriate care.

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Demonstrates working knowledge of performance standards (e.g. Centers for Medicaid and Medicare Services (CMS), National Committee for Quality Assurance (NCQA), Joint Commission, Wisconsin Collaborative for Healthcare Quality (WCHQ) American Academy of Ambulatory Care Nursing (AAACN)

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Demonstrates working knowledge of adult health conditions

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Evaluates and develops learning materials for patients and staff.

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Engage in ongoing learning related to care coordination to advance skills, knowledge and attitudes.

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Promote RNCC to internal and external customers

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Ability to travel to alternative clinical locations, to include those of external organizations affiliated with UW Health as applicable, and provide off-site care.

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Ability to work extended clinical hours (before 8am and after 5pm), based on operational needs and clinical location

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Clinical

Will provide all patients age and culturally appropriate assessment/screening and interpretation of clinical and laboratory data. Develops and implements age appropriate interventional plans of care including education within the parameters of their position responsibilities and licensure

JOB REQUIREMENTS

Bachelor's Degree

in Nursing

Preferred

6 months

RN experience

Required

Previous experience in adult acute care or ambulatory setting

Preferred

Previous Case management experience

Preferred

Registration as a registered nurse in state where employed or licensure in the state  licensure compact

Upon Hire

Required

CPR/BLS

Upon Hire

Required

Case Management Certification

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

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Excellent communication, problem-solving, conflict resolution and interviewing skills.

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Excellent prioritization and organizational skills

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Ability to work as team member and as independent service provider

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Excellent verbal and written communication skills, including grammar and spelling.

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Knowledge and experience documenting in an electronic medical record

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Ability to educate staff

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Ability to provide counseling and emotional support with compassion and respect for the individual

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Ability to provide support to members of the care team

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Ability to maintain confidentiality

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

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Sedentary: Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

☐

Light: Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If someone can do light work, we determine that they can also do sedentary work, unless there are additional limiting factors such as loss of fine dexterity or inability to sit for long periods of time.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

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Medium: Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25 pounds. If someone can do medium work, we determine that they can also do sedentary and light work.

20-50#

10-25#

Negligible-10#

☐

Heavy: Heavy work involves lifting no more than 100 pounds at a time with frequent lifting or carrying of objects weighing up to 50 pounds. If someone can do heavy work, we determine that they can also do medium, light, and sedentary work.

50-100#

25-50#

10-20#

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Very Heavy: Very heavy work involves lifting objects weighing more than 100 pounds at a time with frequent lifting or carrying of objects weighing 50 pounds or more. If someone can do very heavy work, we determine that they can also do heavy, medium, light, and sedentary work.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.