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Case Coordinator

Requisition ID:

21158316

Business Unit:

Hartford Hospital

Location:

Hartford, CT

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Description

Job Schedule: Full Time
Standard Hours: 40
Job Shift: Shift 1
Shift Details: Mon - Fri 8:00 - 4:30

 

Work where every moment matters.

 

Every day, almost 30,000 Hartford HealthCare employees come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut’s most comprehensive healthcare network.

Hartford Hospital is one of the largest and most respected teaching hospitals New England. We are a Level 1 Trauma Center that provides cutting edge treatment to its patients. This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education, Simulation and Innovation (CESI), one of the most-advanced medical simulation training centers in the world. When hospitals cannot provide the advanced care, expertise and new treatment options their patients require, they turn to us.

 

Job Summary:

The Case Coordinator – Outpatient at Adult Primary Care (APC) participates in an expanded nurse role as an integral member of the primary care team. The Case Coordinator works in a collaborative environment with the interdisciplinary team (including but not limited to the patient, patients family, clinic medical team, social workers, hospital case coordinators, hospital complex care team, home care agencies), focused on a patient centered medical home (PCMH) care model. The Case Coordinator must possess our institutional values of integrity, kindness, safety, nurse excellence, leadership, and professionalism while providing high quality safe care. Under the direction and general supervision of the Nurse Manager, the Case Coordinator utilizes evidence based practices in accordance with the State Nurse Practice Act, policies and procedures of the hospital and as directed by the medical staff. With a goal of reducing readmissions and improving quality of life for patients, the Case Coordinator uses expert knowledge and the nursing process to develop a plan of care which includes standards of practice to meet the physical, emotional, spiritual, cultural, and educational needs of the patient and family. The Case Coordinator provides individualized care, implementing interventions including medication education, disease process education and on-going counseling, promotion of self-care, and adherence to an individualized care plan.  The Case Coordinator provides information and guidance to the patient and/or caregiver resulting in effective care transitions, improved self-management skills and knowledge of their illness and or disease process in addition to supporting enhanced communication between the patient and the healthcare team.

Job Responsibilities:

  • Monitor inpatient admissions of APC patients and subsequent discharges, assist with transitioning complex case/high risk patients in collaboration with hospital team, PCP, home care agencies, etc.; work with interdisciplinary team to review cases and risk stratify inpatients to act upon any identified issues while patient is admitted
  • Meet patient at the bedside before discharge, as appropriate (complex/high risk cases), to educate patient on follow up, set expectations, and discuss services that will be provided by Case Coordinator at APC
  • Develop a self-management action plan of care, coordinate services and navigate the patient through the healthcare system with a goal of enabling the patient and family to effectively manage their condition(s) and optimize outcomes
  • Attend and engage in team meetings at APC including but not limited to staff meetings, Ambulatory Care Operations meetings, Readmission Avoidance Committee meetings,
  • Perform outreach calls post-hospitalization for all admitted APC patients
  • Assist APC program in implementing Transitional Care Management and Chronic Care Management billing for Medicare patients, per CMS billing guidelines
  • Partner with PCP and care team (clinic nurse, social work, psych, etc.) for high risk/complex patient appointments at APC
  • Be an integral part of the Complex Transition Workflow for transitions from/to APC/ Hartford Hospital for high risk/complex patients
  • Goals of the position are to reduce readmissions, decrease inappropriate ED utilization, increase care coordination for patients through the care continuum, improve health equity for vulnerable populations, educate and advocate for patients to follow patient centered care plans, increase collaboration of the care team for high risk/complex patients
  • Identify, execute, and track needed referrals to care and community services
  • Document all communication with patient and or care team in EPIC

 

 

Qualifications

  • BSN required, MSN preferred
  • Five (5)  years nursing experience
  • Current CT RN license
  • BLS Certification
  • expected to obtain CCM/CCCTM certification within two years of hire
  • Bilingual Spanish (verbal and written) strongly preferred

We take great care of careers.

With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth.  Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children.  We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance.  Every moment matters.  And this is your moment.

 
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