1. Patient Information Analysis:

• Uses assessment skills and appropriate risk assessment tools to identify patients with actual or potential health care needs that would require care coordination.
• Collaborates with patient/family in establishing mutual goals based on the patient's needs or problems.
• Evaluates, compares and interprets ambiguous and changing patient data.
• Explores patient's understanding and knowledge of current health status.

• Applies nursing judgment to determine level of care assigned or delegated.
• Uses knowledge of complex physiology to monitor, detect and anticipate early and subtle health status changes.
• Monitors, trends and records patient response to disease, illness, treatment.

• Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources.
• Accountable for individualized plan of care and its delivery.

a) Applies expertise to solve problems, generate ideas, plan care, teach and create new services.
b) Assigns Standards of Care
c) Uses scientific background, knowledge of change theory, ability to work with an interdisciplinary team, psychosocial skills and creative strategies to ensure quality, effective, evidence based and cost efficient care for the patient.
d) Collaborates with patients about plan of care.
e) Guides development of multiple health care partnerships to achieve a positive health effect.

• Maintains purposeful therapeutic presence with patients based on nursing judgment.
• Provides care based on patient complexity and nursing judgment.
• Uses patient's perspective to support informed decision-making.

• Anticipates future needs and educates or refers to valid sources of information.
• Understands the patient's unique perspective and assures right education, right time, right environment for learning.
• Evaluates outcome of learning.

• Delegates care based on situation.
• Fosters teamwork and respect.
• Assures effective use of staffing resources.
• Supports assistive personnel: Serves as a resource and holds assistive personnel accountable to complete delegated tasks.

• Ascribes to the ANA Code of Ethics for professional nursing practice.
• Commits to culturally congruent care.
• Commits to continuous learning.
• Participates in education of nursing colleagues and students.
• Commits to evidence-based practice and the conduct of nursing research.
• Commits to mission, vision and values of organization and to the profession of nursing.

• Creates an environment that assures patient safety.
• Promotes healing by creating an environment that conserves patient energy.
• Instills confidence in the patient's own ability to regain/optimize their own health.
• Partners with patient to help them integrate health status changes into their life.

• Continually evaluates the data to further refine the referral criteria to the RN CC caseload; provides feedback to staff to improve the referral process.
• Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications or increased cost.
• When appropriate, integrate care coordination with disease management efforts to achieve low cost interventions that achieve the greatest benefit and increase the accountability of patients for management of their disease.

Education and Learning:

REQUIRED Associate degree in Nursing. Registered nurses without a baccalaureate degree will be required to get a Bachelor's degree in Nursing within six years of hire date.

DESIRED Bachelor's degree in Nursing

Work Experience:

REQUIRED 3-4 years of RN experience in nursing for Hospice care coordinator positions and 5 to 7 years of experience for Care Coordination care coordinator positions

License and Certifications:

REQUIRED

Registered Nurse (RN) licensed minimally in the state of practice, some positions may require additional state RN licenses.
Current Infant-Adult Basic Life Support for Health Care Providers (with hands on learning) from one of the following programs; American Heart Association or American Red Cross.

DESIRED

RN Specialty Certification

Environmental Conditions:

Exposed to infectious diseases.

Physical Requirements/Demands of the Position: