About Job

Job Summary

The Registered Nurse (RN) or Licensed Practical Nurse (LPN) ensures patients receive the highest level of care possible by coordinating and managing the Valley Health Care patient population by utilizing nursing skills, as well as working well with community resources. The Care Coordinator will apply nursing theory, knowledge, and ethics including assessments, planning, intervention, evaluation, and case management. This position requires strong social skills like communication and empathy, as well as a deep understanding of the healthcare and social welfare systems.

DUTIES AND RESPONSIBILITIES

Research, identify, and link resources and services to support patients.
Initiate family contacts and develop ongoing processes for families to determine the level of patient navigation each patient requires.
Assess patients and/or family needs which are unmet, and coordinate to ensure these basic needs are met, if possible.
Assist with and promote the identification of those with special health care needs.
Communicate effectively to decrease patient worry and frustration and enhance self-management skills.
Promote timely access to appropriate care.
Assistance with basic needs.
Specific referrals, if necessary (examples: hospice, palliative care)
Assist with programs developed to facilitate cohesive relationships.
Main point of contact with patients.
Provides quality chronic care management services and transitional care management services to selected populations based on risk/need.
Utilizes technological tools to manage population.
Informs the patient and family regarding coordination of their care, and shares information with the patient’s care team.
Assess patient compliance with plan of care.
Ensures care gaps are closed around specialty disease/chronic disease.
Communicates with patients as appropriate.
Helps patients understand their illness or condition and provide them with information about resources available to them to cope with the emotional, financial, and social needs that arise with a diagnosis.
Assesses the unique needs and situation of each patient. This means assessing the overall wellbeing of patients to understand what they require and how the social worker can support them.
Creates care plans.
Advocates for patients.
Educating and supporting patients. Act as a go-between for medical staff and patients and translate potentially complex or confusing medical information to ensure patients understand what is happening at all stages.
Build a professional and cohesive relationship to make any necessary changes.
Other duties as assigned.