Throughout the COVID-19 pandemic, Saint Luke’s Health System is committed to providing exceptional care for all patients and a safe and healthy atmosphere for our team.

Person, Nurse, Doctor

RN Care Coordinator Saint Luke's At Home, Full Time.

Kansas City, Missouri.

JobReq0023247

 

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RN Care Coordinator Saint Luke's At Home

  • 901 E 104 St, Saint Luke's Heath System - Headquarters, Kansas City, Missouri, United States, 64131
  • Case Management
  • Full Time

Job Description​

The Population Health Team within the Saint Luke’s Physician’s Group (SLPG) supports programs that foster the delivery of an innovative integrated care model across the Kansas City Metro and beyond.  

Saint Luke’s At Home delivers tailored healthcare in the home to patients who have multiple chronic illnesses and challenges managing their health. Similar to what you would expect from a Primary Care practice, but we bring the care to where it is needed the most –  the home. The aim is to keep patients healthier, enhance the quality of life, and prevent illnesses from escalating to where treatment in the emergency department or hospital setting would be required.

To achieve this, multidisciplinary clinical teams integrate technology with a highly innovative care delivery model. 
 

The Population Health Care Coordinator in our Saint Luke's At Home department is tasked with care coordination for a panel of moderate to high risk patients. This role functions as a part of the care team, collaborating across the continuum of care to provide complex disease management interventions to moderate/high risk patients.

RESPONSIBILITIES

  • Acts as an advocate for the patient in all activities including nursing assessments, care coordination, care plan development, and communication.  
  • This position is accountable for identifying and developing innovative actions to meet the needs of the patient from both the health care and psychosocial / socioeconomic dimensions of care as well as acting for provision of services to meet those needs.  
  • Assist with completion of the initial patient assessment, including a medical record review where available  
  • Documentation of current advance care directive status and ongoing efforts to reconcile patient/caregiver misaligned goals with current clinical status  
  • Perform ongoing assessments commensurate with patient risk level and/or identified need  
  • Collaboration with multi-disciplinary team to develop plan of care, establishing a collaborative approach to patient needs across clinicians and care delivery  
  • Initiate and maintain ongoing communications with clinicians involved in patient care, especially PCP  
  • Meet with families/responsible parties for collaboration on patient plan of care and discussion of patient/family/responsible party contribution to the ongoing management of patient condition  
  • Coordinate care across the continuum of care delivery model as the point of contact for patient/caregiver and clinicians  
  • Act as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives or equipment that will aide in the safety of the patient while promoting optimal clinical outcomes  
  • Monitor patient progress to plan of care goals with emphasis on patient care need during transitions and changes in member level of care needs  
  • Monitor patient during admissions to both acute and skilled level of care to support patient needs, establish as the point of contact to clinicians and patient/responsible party/families to ensure consistent and ongoing communication between all involved parties  
  • Main educator for patients and/or families/responsible parties on disease processes and ways to manage disease progression as independently as possible  
  • Reviews medical information collected including medical records and/or performs additional assessment to facilitate medical necessity determinations regarding service requests as established with in the identified program guidelines and the state established nurse scope of practice  
  • Serve as a resource to the entire care delivery team  
  • Identification and reporting of any quality of care issues  
  • Maintain HIPAA compliance as it relates to patient care  
  • Attend departmental meetings and daily huddles
  • Completes other duties as assigned 

Job Requirements

Applicable Experience:

3-5 years

Basic Life Support - American Heart Association or Red Cross, Registered Nurse - Various

Bachelor's Degree (Required)

Job Details

Full Time

Day (United States of America)

"The best place to get care. The best place to give care." That is the Saint Luke's vision and, whether in a hospital, clinic, practice, or office, our more than 12,000 employees strive toward that vision every day. Saint Luke's employees are proud of our rich history and heritage, and that we remain the only faith-based, nonprofit, locally owned health system in Kansas City. Joining Saint Luke's means joining a team of exceptional professionals who always strive for excellence in patient care. Take this opportunity to do the best work of your career within a highly diverse and inclusive work space where all voices matter.

Join the Kansas City region's premiere provider of health services. Equal Opportunity Employer. We hire only non-tobacco users.

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