Care Coordinator

Tahoe Forest Health System; Truckee (CA); On-site; USD 96,000 - 117,000; Full time

Job summary

Tahoe Forest Health System is seeking a Registered Nurse Care Coordinator in Truckee to oversee care coordination for medically complex patients. You will develop individualized care plans, educate patients, and coordinate with clinicians and community resources to improve outcomes.

You will collaborate with a diverse healthcare team, monitor progress, and support transitions of care through home and clinic visits, while ensuring adherence to clinical protocols and patient safety.

Qualifications

• Requires RN licensure in California and BLS certification.
• Experience coordinating care across healthcare teams and community resources is essential.
• Strong communication and patient education skills are required.

Responsibilities

• Coordinate care for medically complex patients with a patient-centered plan.
• Collaborate with healthcare team and community partners to optimize outcomes.
• Educate patients and families and support self-management of chronic conditions.
• Ensure medication management and health resource referrals are accurate.
• Maintain EMR documentation and continuity of care across visits and settings.

Skills

Care coordination

EMR proficiency

Communication

Patient education

Education

California Registered Nurse (RN)

Basic Life Support (BLS)

Tools

EMR system

Job description

Job Category: EAP

Requisition Number: CAREC004607

• Full-Time
• On-site

Locations

Showing 1 location

Truckee, CA, USA

Description

Bargaining Unit: EAP

Rate of Pay: $73.72/hour + DOE

Summary

The Registered Nurse Care Coordinator is responsible for the overall care coordination of medically complex patients, including medical care, education, internal and external referrals and referrals to community resources. The Care Coordinator works with each patient to develop a patient-centered plan of care specific to their needs and self-management goals. Additionally, the Care Coordinator actively collaborates with the diverse healthcare team and local community partners to improve patient health outcomes.

Essential Duties and Responsibilities

Performs the nursing process through assessment, planning, implementation and evaluation of safe therapeutic care to develop patient-entered plan of care to medically complex patients.

• Actively collaborates with healthcare team as an advocate.
• Assists patients through the healthcare system and community by acting as a patient care coordinator.
• Facilitates health and disease patient education through individual teaching and class teaching as indicated.
• Supports patient self-management of disease and behavior modification interventions.
• Assures home monitoring and patient knowledge that is consistent with treatment plan as indicated.
• Coordinates continuity of patient care with internal and external healthcare providers.
• Attends clinic visits, field visits and home visits as indicated to monitor patient progress and assess needs.
• Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Facilitates patient medication management based upon medication reconciliation process.
• Connects to community resources as indicated per Social Drivers of Health assessment.
• Participates on a team for data collection, health outcomes reporting, and clinical audits.
• Demonstrates System Values in performance and behavior.
• Complies with System policies and procedures.
• Other duties may be assigned.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Supervisory Responsibilities

No supervisory responsibilities.

Associate's Degree Degree from college or vocational school from a National League of Nursing (NLN), Commission on Collegiate Nursing Education (CCNE) or equivalent accredited school of nursing. The nurse shall have completed a nursing education program that included clinical experiences with actual patients under the supervision of qualified faculty

6 months to 1 year relevant experience

Required Licenses/Certifications

California Registered Nurse (RN)

• Upon hire
• Within 3 months of hire into job

Basic Life Support (BLS) for Healthcare Providers Upon hire BLS: Employee will be enrolled in the Resuscitation Quality Improvement (RQI) Basic Life Support (BLS) Entry or Prep Curriculum (depending on their previous BLS certification).

Within 3 months of hire into job

Other Experience/Qualifications

Required:

Self-disciplined, energetic, passionate, and innovative

Collaborative team member that follows systems and protocols to achieve a common goal

• Highly organized and well-developed oral and written communication skills
• Demonstrates sound judgment, decision-making and problem-solving skills
• Ability to maintain confidentiality with all aspects of information in accordance with practice, State and Federal regulations
• Confidence to communicate and outreach to other community health care organizations and is aware of community resources
• Demonstrated computer skills
• Proficiency using Electronic Medical Record (EMR)

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.