The RN care coordinator will coordinate team-based care to provide health services and education to patients and families through effective partnerships with the Diagnostic Referral Department (DRS), medical professionals and community resources. Provides care coordination to the medically complex population by utilizing critical thinking skills and nursing expertise in order to optimize patient outcomes for designated populations within DRS and other specialty clinics, as required. Works with patients and families to ensure both medical and psychosocial needs are met to promote health and well-being. Addresses gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk.

The care coordinator is accountable for adherence to policies and procedures of Nemours Children's Health, Delaware Valley and other affiliated hospitals to which Nemours-delegated patients are admitted/seek care.

The care coordinator is expected to maintain all state and federal clearances for DE.

Assist with the identification of patients within the Diagnostic Referral Department, other specialty teams and medical professionals who require care coordination assistance as related to chronic care needs, needs related to Social Determinants of Health (SDOH), and coordination of services.

Identifies patient and family gaps in care and/or barriers to care and patient/family strengths and assets. Identify patients at risk for poor transitions, high Emergency Department utilization and/or readmission to hospital. Will complete a comprehensive transition assessment and plan for on-going touchpoints for these patients. Will communicate needs and plan to providers, care team, outpatient care coordinators and, care managers, if referral is indicated.

Initiates family contacts and facilitates patient access to, and communication between physicians and other team members.

Works cooperatively with families, patients, other members of the treatment team, social service agencies, community resources, and public agencies. Collaborates with the family and team to arrange for health care needs. Acts as a liaison for agencies and families with identified healthcare needs.

Utilizes the nursing process to coordinate the care of an identified population of pediatric patients throughout the healthcare continuum.

Assists families and patients through the healthcare system by acting as patient advocate and navigator connecting patients to relevant community resources with the goal of enhancing patient health and wellbeing.

Serve as point of contact, advocate and informational resource for family, patient, care team, school systems and their school nurses, community resources, and state agencies. Facilitates meetings/calls between patient /family, care team, payors, and outside agencies as needed.

Collaborates with providers, case managers, social workers and related care teams to understand care, treatment goals and overall plan of care.

Educates patient/family about a condition (existing or newly diagnosed) to assist them in appropriate self-management.

Participates in data collection, health outcomes reporting, clinical audits, and program evaluation. Assists with the identification of areas for improvement within their practice.

Monitors specialty consults and follows up if patient/family did not follow through with the appointment or the consult report was not received by the PCP.

Makes appropriate referrals to case managers and care managers

Makes appropriate referrals to home care, durable medical equipment (DME), and pharmacy vendors. Provides after visit summaries and other pertinent information related to on-going care in the home or placement.

Requirements-

Bachelor's Degree

RN Licensure and BSN degree required

Case Management Certificatoin Preferred: CCM, ACM-RN

5+ Years relevant Experience