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Ambulatory RN Care Coordinator

Overview:

Works under the supervision of the Manager and the Director and is responsible for working in collaboration with the healthcare team to coordinate the care and service to patients across the continuum of care, promotes effective utilization and monitoring of healthcare resources and assumes a leadership role with the interdisciplinary team to achieve optimal quality, clinical and resource outcomes. Works under the direction of the leadership team to provide a comprehensive range of services or clinical care associated with and in accordance with standards of excellence established by Riverside Health system and facility goals and strategic plans. The Care Coordinator maintains an average case load of 50-100 patients with complex and/or chronic health needs, addresses social determinants of care, and provides navigation for the patient throughout the care continuum to assure seamless transitions of care. Works closely with other team members in the case management functions in the inpatient setting, LLH, and remote monitoring/connected care center. Maintains relationships with key community partners, develops longitudinal care plans based on the patents goals, and communicates with patients in office, virtually, telephonically and/or through home visits.

This position will serve the Northern Neck region and will be based out of 3 different Medical Group practices located in Callao, White Stone, and Warsaw

Qualifications

Education:
Must have graduated from an RN program, BSN is preferred but not required.
Experience:
3 or more years of clinical experience is required. LPN experience is acceptable. Previous Case Management specific experience is preferred.
License/Certification:
VA State RN License in good standing required.



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