Minimizes fragmentation in the health care system while applying standards of care to promote collaborative care coordination, navigating transitions of care, and incorporating adherence to guidelines and regulations. The RN continuity of care coordinator will be recognized as an expert and vital participant in the care coordination team who empowers health care providers to understand and access quality, safe, and efficient health care services. (CM standards)
- Assures the discharge plan is in alignment with providing choice, assuring safety, and is timely and cost effective. (CM standards)
- Uses evidence based practice to determine correct level of care for all patients, medical necessity is met, and findings are documented from time of admission and upon discharge. (CM standards)
- Uses a patient centered, collaborative partnership approach that is responsive to the individual patient’s culture, preferences, needs, and values.
- Maintains compliance with federal, state, and local rules and regulations, and organizational, accreditation, and certification standards.
- Uses a comprehensive, holistic, and compassionate approach to care delivery which integrates a client’s medical, behavioral, social, psychological, functional, and other needs. Develops, intervenes, and evaluates the plan of care in collaboration with patients, families, and other team members. (CM standards)
- Interfaces with referring agencies and insurance companies to ensure appropriate levels of care and maximum reimbursement for out-of-home and home care needs, including but not limited to: DME, pharmaceuticals, home nursing care, and social services.
- Provides education to other members of the health care team regarding current regulatory agency guidelines and subsequent requirements for appropriate documentation. Provides patient education using methods and approaches recognizing the specific needs and care of the individual patient (SP 5b).
- Provides education to using methods and approaches recognizing the specific needs and concerns of the patient; supports the patient and caregiver(s) to become informed customers about options, costs, risks, and benefits of health care services (SP5a).
- Participates in projects, activities, committees, related to nursing and health care in clinical and organizational settings.
- Supports quality improvement, evidence base practice, and research that will contribute to patient care standards, staff development, and the mission of the institution.
- Accountability: Accepts full responsibility for self and contribution as a team member; displays honesty and truthfulness; confronts problems quickly; displays a strong commitment to organizational success and inspires others to commit to goals; demonstrates a commitment to National Jewish Health.
- Collaboration/Teamwork: Cooperates with others to accomplish common goals; works with employees and across his/her department to achieve shared goals; treat others with dignity and respect and maintains a friendly demeanor; values the contributions of others [SPP 10].
- Ethics: Practices ethically; Integrates the ANA Code of Ethics for Nurses with Interpretive Statements to guide practice; demonstrates compassion and respect for the inherent dignity, worth and unique attributes of all people; advocates for healthcare consumer’s rights to informed decision-making and self-determination; maintains therapeutic relationships and professional boundaries; safeguards privacy and confidentiality of healthcare consumers, and their data and information [Standard of Professional Performance (SPP) 7].
- Evidence-based Practice and Research: Integrates evidence and research findings into practice; Articulates the values of research and its application relative to the healthcare setting; identifies questions in the healthcare setting and practice that can be answered by nursing research; uses current evidence-based knowledge, including research findings, to guide practice; incorporates evidence when initiating change in practice [SPP 13
- Informing and Communicating: Clearly conveying information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message [SPP 9].
- Leadership: Encourages innovation in practice and role performance to attain personal and professional plans, goals, and vision; manages change and conflict; retains accountability for delegated nursing care; contributes to the evolution of the profession through participation in professional organizations. [SPP 11].
- Professional Development: Actively identifies in new area with preceptor learning opportunities and unit specific competencies; regularly creating and taking advantage of learning opportunities; using newly gained knowledge and skill to enhance contribution to the organization [SPP 12, 15].
- Quality of Practice: Contributes to quality nursing practice: Ensures practice is safe, effective, efficient, equitable, timely, and patient centered; identifies barriers and opportunities to improve safety, effectiveness, efficiency, equitability, timeliness, and patient centeredness; recommends strategies to improve nursing quality [SPP 14].
Supervisory or Managerial Responsibility
- Be available to work as scheduled and report to work on time.
- Be willing to accept supervision and work well with others.
- Be well groomed, appropriately for your role and wear ID Badge visibly.
- Be in compliance with all departmental and institutional policies, the Employee Handbook, Code of Conduct and completes NetLearning by due date annually.
- Fosters an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the institution.
- Adheres to safe working practices and at all times follows all institutional and departmental safety policies and procedures.
- Wears appropriate PPE as outlined by the infection control policies and procedures.
- Demonstrates compliance with all state, federal and all other regulatory agency requirements.
Graduation from an Accredited School of Nursing required, BSN preferred.
A minimum of two years of recent and related Registered Nurse (RN) experience required. One year of Acute Care or Case Management experience preferred.
Special Training, Certification or Licensure
Current Colorado Registered Nurse (RN) License and current CPR/BLS certification required. ACLS or PALS if applicable for specific unit required. Certification in a relevant specialty preferred.