The RN Coordinator serves as the key contact point for the patient to coordinate and streamline all services offered within Evernorth. The RN Coordinator will educate the patient on healthcare options, provide patient education and answer questions as they arise. The RN Coordinator will be compassionate and positive who inspires confidences in the patients they work with. The RN Coordinator will work hand in hand with patients, other staff and providers to help answer any questions they have in regard to schedules, appointments, orders, consults, etc. The RN Coordinator will be responsible for knowing where to look for all of the members information and directing and delegating tasks to team members as needed.Key ResponsibilitiesCore Responsibilities1. Be the point of contact for all aspects of the member in regard to their appointments, care, and overall health.2. Act as the liaison between the providers and their patient panel, directing and delegating tasks to team members3. Educate patients about their care options and make specific recommendations based on their goals4. Review paperwork for patients to ensure it meets all requirements5. Explain test results, diagnoses and other medical outcomes6. Cover any additional triage and transition of care for patients as neededHealth Literacy Improvement
1. Improves health literacy and coaches patients on chronic conditions including disease process and trajectory, medication education including possible side effects, plan of care, and individualized care goals management in a culturally sensitive and acceptable manner for the patient or caregiver.
2. Identifies problems or gaps in care and offers opportunity for intervention
3. Coordinates services and referrals to health programs and participates in patient education and outreach tied to HEDIS initiatives
4. Works to improve access to care and works as part of the team to manage heath care cost and utilizationProvider Support
1. Completes telephonic nursing assessments including social determinants of health screenings, post hospital discharge screenings, triage, and other assessments assigned by provider
2. Assists with organizing and running a chronic care and/or interdisciplinary care team rounds where high risk patients and care plans are identified
3. Participate using a team approach to create a care plan for the patient
4. Maintain and update spreadsheets and documents provided by health plan to prep weekly rounds of documentationPost-Acute Management and Coordination
1. Participation in weekly care coordination with health plan case management as directed by market needs
2. Referral Management Care Coordination and tracking of hospice consults within 24 hrs. of order placementDiagnostics and Lab Result Management
1. Obtain Pre Authorization for all CT, MRI, Echo\xe2\x80\x99s ordered by providers (Pt Coordinators to schedule)
2. Serves as a guide in their POD for all escalated orders and results as clinically appropriateAdditional Responsibilities:Nursing Triage
1. Assess and triage immediate health concerns transferred to nursing team by clinical support staff.
2. Provide telephonic nursing assessment and triage supported by triage protocols. This includes, timely and accurate triage documentation, escalation, and follow up
3. Initiate medication changes and other orders, as directed by provider in response to a triage call.Transition of Care
1. Monitors daily discharge list and develops a plan to schedule transition of care visits within the allotted timeframe2. Complete telephonic post-discharge hospital visits and ask pertinent discharge triage questions and complete medication reconciliation
3. Document all findings and make appropriate referrals to social work, pharmacy, case management and engagementOther telephonic patient care and provider support duties as assignedCompetencies:
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