RN Care Coordinator, Population Health (Finance)
At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.
As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors.
UC Health is committed to providing an inclusive, equitable and diverse place of employment.
The RN Care Coordinator will manage staffing, clinical competencies, and provide clinical services on the Hamilton County 513 Relief Bus and in the Greater Cincinnati community. UC Health will staff the 513 Relief Bus to provide healthcare services, such as blood pressure, glucose, and cholesterol screenings, multiple times a week. This position will be in office several days a week when there are not community events, during which the position will be focused on coordinating services to be provided on the bus, relationship building with internal and external partners, and project management of additional community health work connected to system priorities.
The Hamilton County 513 Relief Bus provides Health Screenings, Social Services & Economic Relief to our community. Funded by the Hamilton County Commissioners, the 513 Relief Bus provides resources directly to residents using a community-based approach. The bus is a mobile medical and social service bus. The bus is equipped with the technology to provide an array of services from healthcare to enrolling in relief programs for Hamilton County residents. Epic will be available on the bus so that proper documentation can take place as well as the ability to schedule appointments.
- The 513 Relief Bus delivers no-cost resources that provide stability.
- The 513 Relief Bus connects with residents by bringing resources into the neighborhoods and spaces where they live, work, and play.
- The 513 Relief Bus removes barriers such as access, transportation, and technology.
In addition to the RN Care Coordinator responsibilities listed below, this position will have additional project management responsibilities including:
- Responsible for supporting the development, implementation and tracking for key metrics to track community impact of our services.
- Think creatively to develop and streamline operational and system updates, define workflows and process maps, to proactively plan and implement improvements.
- Use a proactive approach, along with key planning skills to advance future efforts and activities.
- Communicate to internal groups the status of current, on-going, and prospective community events with clear details, critical timelines, and expectations.
- Work with leadership and UC Health marketing partners and/or vendors to manage communication content and leverage resources across the UC Health network.
- Advocate for resources, collaborations, and future changes to support healthcare innovation.
- Partner with system resources to optimize program initiatives.
Current Registered Nurse (RN) license in the state of Ohio. Basic Life Support (BLS) certification preferred.
Minimum Required: Minimum of 2 years of nursing experience in an ambulatory or outpatient setting.PATIENT POPULATION - (CLINICAL ONLY):
• Engages in population appropriate communication.
• Has knowledge of growth and development milestones and tasks.
• Gives clear instructions to patients/family regarding treatment.
• Involves family/guardian in the assessment, initial treatment and continuing care of the patient.
• Identifies any physical limitations of the patient and deploys intervention when necessary.
• Recognizes and responds appropriately to patients/families with behavioral health problems.
• Interprets population related data and plans care appropriately.
• Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms. Performs treatments, administers medication or operates equipment safely.
• Recognizes and responds to signs/symptoms of abuse or neglect.
PATIENT ASSESSMENT & INTERVENTIONS:
• Acts as an expert clinician and role model in providing quality patient care to patients and their families within his/her specialty area.
• Utilizes the nursing process for direct patient care and assists the staff with assessment, planning, implementation, and evaluation of patient care needs.
• Conduct thorough assessments of patients' health status during clinic visits. Reassess and evaluate patient as needed throughout their visit.
• Document nursing history and assessment for assigned patients, initiating referrals based on patient needs.
• Collects basic level and advanced patient data. Monitors for trends that could impact patient health.
• Maintain awareness of comfort and safety needs of patients during their ambulatory appointment starting from the time they arrive to their departure. Assess patient environmental safety continuously.
• Respond to life-saving techniques based on nursing standards, policies, procedures, and protocol.
• Provide accurate hand-off report when patients are moved between ambulatory areas and/or between ambulatory and inpatient areas.
• Recognizes and reports changes in patient conditions and abnormal labs or results.
• Perform POC testing assessments as needed to support the patient's clinical well-being and also patient experience.
• Initiate and implement individualized patient care plans in collaboration with other healthcare providers based on clinical assessments, disease process, and patient's identified psychosocial needs.
• Collaboratively develops and utilizes patient care pathways that ensure consistent quality of care for patients.
• Demonstrates competency in administering medications, perform wound care, and provide other direct nursing interventions as needed.
• Completes nurse visits and documents timely and accurately.
• Assist with minor procedures and diagnostic tests, ensuring patient comfort and safety.
• Monitor patients for changes in condition, report findings to the healthcare team, and adjust care plans accordingly.
• Recruit patients for studies
• Assists and collaborates with staff nurses in quality assurance.
• Meet new patients to introduce self and explain role.
• Demonstrates ability to establish priorities of care based on individual patient assessments and the needs of the patients assigned.
• Demonstrates critical thinking and accountability in evaluating and implementing physician orders.
• Ensures timely nursing documented with exceptional accuracy according to hospital policy and procedures. Real time nursing documentation.
• Maintain positive, professional, and cooperative demeanor throughout all interactions with patients, staff, physicians, and members of management. Maintain a calm demeanor during emergent or challenging behavioral situations with patients.
PATIENT EDUCATION:
• Meets with patients and families to identify educational needs related to health promotion, maintenance, alterations in health status, disease processes, diagnostic testing, and interdisciplinary care within specialty area.
• Educate patients and their families about health conditions, treatment plans, medications, and self-care techniques.
• Reassess for understanding and re-educate as needed.
• Apply current nursing literature in teaching techniques and guiding standards of care in patient and family education.
• Serve as a expert patient educator for disease-based and clinic-based care teams.
• Documents patient/family/designee teaching and response appropriately.
FACILITATION OF CARE:
• Facilitate seamless transitions of care by coordinating referrals, scheduling follow-up appointments, and ensuring timely access to services throughout continuity of care.
• Communicate effectively with patients regarding test results, treatment plans, and follow-up care.
• Address patient concerns and provide support and guidance throughout their treatment journey.
• Anticipate changing needs of patients and families based on care plan and act proactively to reduce delays in care, reduce financial toxicity, and increasing patient satisfaction.
• Participate in interdisciplinary team meetings to discuss patient care.
• Collaborate with social workers, dietitians, and other healthcare professionals to address the comprehensive needs of patients.
• Liaison to other departments and organizer for interdepartmental projects
• Participates in transitions of care planning.
• Documents plan of care reflective of collaborative practice with other health care team members.
• Support prior authorization for medication and diagnostic tests
LEADERSHIP & PROFESSIONAL DEVELOPMENT:
• Serves on nursing and hospital-wide and unit-based committees that influence the delivery of patient care (example: PPO, Documentation)
• Assists with developing and revising policies and procedures for nursing practice.
• Assist with implementing evidence-based practice in the unit.
• Works collaboratively on performance improvement system wide.
• Demonstrates the nurse's role as a member of the healthcare team and promotes accountability, responsibility, and commitment regarding patient care standards.
• Serves as a resource within his/her own specialty for all members of the healthcare team.
• Orientation and other education programs as assigned.
• Serve as a preceptor and/or mentor for nursing students, clinical interns, and other healthcare professionals as needed and identifies opportunities for observation or clinical experiences.
• Remains current in research to area of clinical nursing practices
• Participates and contributes to staff meetings
COMPLIANCE & SAFETY:
• Maintains confidentiality of information
• Sustain an understanding of regulatory requirements and accreditation standards.
• Monitor safety and departmental policies and procedures.
• Work with department managers, nurses and nursing leadership and multidisciplinary representatives to identify and share safety best practices.
• Demonstrate an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, UC, legal P&P) impacting the care delivery and reimbursement process.
• Utilizing MIDAS effectively to report safety concerns. Able to escalate appropriately.
OTHER DUTIES AS ASSIGNEDPATIENT POPULATION - (CLINICAL ONLY):
• Engages in population appropriate communication.
• Has knowledge of growth and development milestones and tasks.
• Gives clear instructions to patients/family regarding treatment.
• Involves family/guardian in the assessment, initial treatment and continuing care of the patient.
• Identifies any physical limitations of the patient and deploys intervention when necessary.
• Recognizes and responds appropriately to patients/families with behavioral health problems.
• Interprets population related data and plans care appropriately.
• Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms. Performs treatments, administers medication or operates equipment safely.
• Recognizes and responds to signs/symptoms of abuse or neglect.
PATIENT ASSESSMENT & INTERVENTIONS:
• Acts as an expert clinician and role model in providing quality patient care to patients and their families within his/her specialty area.
• Utilizes the nursing process for direct patient care and assists the staff with assessment, planning, implementation, and evaluation of patient care needs.
• Conduct thorough assessments of patients' health status during clinic visits. Reassess and evaluate patient as needed throughout their visit.
• Document nursing history and assessment for assigned patients, initiating referrals based on patient needs.
• Collects basic level and advanced patient data. Monitors for trends that could impact patient health.
• Maintain awareness of comfort and safety needs of patients during their ambulatory appointment starting from the time they arrive to their departure. Assess patient environmental safety continuously.
• Respond to life-saving techniques based on nursing standards, policies, procedures, and protocol.
• Provide accurate hand-off report when patients are moved between ambulatory areas and/or between ambulatory and inpatient areas.
• Recognizes and reports changes in patient conditions and abnormal labs or results.
• Perform POC testing assessments as needed to support the patient's clinical well-being and also patient experience.
• Initiate and implement individualized patient care plans in collaboration with other healthcare providers based on clinical assessments, disease process, and patient's identified psychosocial needs.
• Collaboratively develops and utilizes patient care pathways that ensure consistent quality of care for patients.
• Demonstrates competency in administering medications, perform wound care, and provide other direct nursing interventions as needed.
• Completes nurse visits and documents timely and accurately.
• Assist with minor procedures and diagnostic tests, ensuring patient comfort and safety.
• Monitor patients for changes in condition, report findings to the healthcare team, and adjust care plans accordingly.
• Recruit patients for studies
• Assists and collaborates with staff nurses in quality assurance.
• Meet new patients to introduce self and explain role.
• Demonstrates ability to establish priorities of care based on individual patient assessments and the needs of the patients assigned.
• Demonstrates critical thinking and accountability in evaluating and implementing physician orders.
• Ensures timely nursing documented with exceptional accuracy according to hospital policy and procedures. Real time nursing documentation.
• Maintain positive, professional, and cooperative demeanor throughout all interactions with patients, staff, physicians, and members of management. Maintain a calm demeanor during emergent or challenging behavioral situations with patients.
PATIENT EDUCATION:
• Meets with patients and families to identify educational needs related to health promotion, maintenance, alterations in health status, disease processes, diagnostic testing, and interdisciplinary care within specialty area.
• Educate patients and their families about health conditions, treatment plans, medications, and self-care techniques.
• Reassess for understanding and re-educate as needed.
• Apply current nursing literature in teaching techniques and guiding standards of care in patient and family education.
• Serve as a expert patient educator for disease-based and clinic-based care teams.
• Documents patient/family/designee teaching and response appropriately.
FACILITATION OF CARE:
• Facilitate seamless transitions of care by coordinating referrals, scheduling follow-up appointments, and ensuring timely access to services throughout continuity of care.
• Communicate effectively with patients regarding test results, treatment plans, and follow-up care.
• Address patient concerns and provide support and guidance throughout their treatment journey.
• Anticipate changing needs of patients and families based on care plan and act proactively to reduce delays in care, reduce financial toxicity, and increasing patient satisfaction.
• Participate in interdisciplinary team meetings to discuss patient care.
• Collaborate with social workers, dietitians, and other healthcare professionals to address the comprehensive needs of patients.
• Liaison to other departments and organizer for interdepartmental projects
• Participates in transitions of care planning.
• Documents plan of care reflective of collaborative practice with other health care team members.
• Support prior authorization for medication and diagnostic tests
LEADERSHIP & PROFESSIONAL DEVELOPMENT:
• Serves on nursing and hospital-wide and unit-based committees that influence the delivery of patient care (example: PPO, Documentation)
• Assists with developing and revising policies and procedures for nursing practice.
• Assist with implementing evidence-based practice in the unit.
• Works collaboratively on performance improvement system wide.
• Demonstrates the nurse's role as a member of the healthcare team and promotes accountability, responsibility, and commitment regarding patient care standards.
• Serves as a resource within his/her own specialty for all members of the healthcare team.
• Orientation and other education programs as assigned.
• Serve as a preceptor and/or mentor for nursing students, clinical interns, and other healthcare professionals as needed and identifies opportunities for observation or clinical experiences.
• Remains current in research to area of clinical nursing practices
• Participates and contributes to staff meetings
COMPLIANCE & SAFETY:
• Maintains confidentiality of information
• Sustain an understanding of regulatory requirements and accreditation standards.
• Monitor safety and departmental policies and procedures.
• Work with department managers, nurses and nursing leadership and multidisciplinary representatives to identify and share safety best practices.
• Demonstrate an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, UC, legal P&P) impacting the care delivery and reimbursement process.
• Utilizing MIDAS effectively to report safety concerns. Able to escalate appropriately.
OTHER DUTIES AS ASSIGNED
