Registered Nurse - Nurse Care Coordinator

Summary: Nurse Care Manager will maintain a patient caseload using a holistic, person-centered approach for coordinating the healthcare needs and wellness goals of the patients.

Essential Duties and Responsibilities: include the following. Other duties may be assigned.

Coordination of care plan with health care team.

Initiates a patient education plan according to the individualized needs of the patient, as prescribed including patient and family instruction.

Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients

Develops, discusses, and communicates a realistic problem list (care plan) for each patient, in collaboration with each patient/family/significant other in order to address all identified needs

Coordinates patient care with external healthcare workers, including providers, pharmacies, and community resource agencies.

Tracks care with patients and provides a rationale for care plan and follow up.

Assist the HCH Director in developing and enhancing wellness initiatives.

Provide education to patients that promotes lifestyle changes; including tobacco cessation and prevention, nutrition, physical and substance abuse prevention

Explains procedures and treatments to patient to gain cooperation, understanding, and allay apprehension.

Make initial contact with hospital within 2 days of notification of patient’s admission, makes a telephonic/face to face patient contact of hospital discharge to reconcile medications and schedule follow-up appointment with PCP

Tracks all required data and submits reporting as indicated by manager.

Maintains up-to-date and accurate documentation of nursing care provided to ensure integration of information used by the healthcare team to ensure quality care and improve outcomes.

Administers prescribed medications and treatments in accordance with approved nursing techniques as needed.

Maintains awareness of comfort and safety needs of patient.

Responds to life saving situations based upon nursing standards, policies, procedures, and protocol.

Documents nursing history and physical assessment for assigned patients.

Participates in department or unit quality improvement activities.

Attend meeting as directed by manager

Education and/or Experience: Must have a Missouri RN License