Job Description:I. Primary Function -The RN care coordinator will coordinate team-based care to provide health services and education to patientsand families through effective partnerships with Delaware Children Health Network (DCHN) practices,community resources and medical professionals. Supports care coordination in the DCHN practice settingby utilizing critical thinking skills and nursing expertise in order to optimize patient outcomes amongstdesignated populations within the practice. Works with patients and families to ensure both medical andpsychosocial needs are met in order to promote health and well-being. Works with DCHN practices toaddresses gaps in care and promotes timely access to appropriate care, increasing the utilization ofpreventative care and healthy behaviors to improve the health of the population at risk.II. Essential Functions -1) Assist with the identification of patients in the practice with special health care needs; by runningregistry reports and use the registries to plan and monitor care. Monitors and audits patientregistries/lists in accordance with NCQA Standards. Assists children with special health care needsand families in obtaining needed care to optimize quality of life and outcomes when possible.Coordinate with insurances to help families understand their benefits.2) Supports DCHN practices to initiate family contacts and facilitate patient access to, andcommunication between, physicians and other team members.3) Identify patient and family needs, gaps and/or barriers to care and patient/family strengths andassets. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse,complex medical patients, behavioral health issues, etc. facilitating appropriate connection toresources available to assist the patient and family to meet needs and overcome barriers to care.4) Works cooperatively with families, patients, other members of the treatment team, social serviceagencies, community resources, and public agencies. Collaborates with the family and team toarrange for health care needs. Acts as a liaison for agencies and families with identified healthcareneeds.5) Utilizes the nursing process to coordinate the care of an identified population of pediatric patientsthroughout the healthcare continuum.6) Supports DCHN practices in coordination of services such as, transportation, interpreter needs,SDoH resources, referrals, and compliance. Assists families and patients through the healthcaresystem by acting as patient advocate and navigator connecting patients to relevant communityagencies and resources with the goal of enhancing patient health and wellbeing.7) Serve as point of contact for DCHN practices as an informational resource for family, patient, careteam, school systems and their school nurses, community resources, and state agencies.8) Works with DCHN practices to re-educate patient/family about a condition (existing or newlydiagnosed) to assist them in appropriate self-management; referring to Care Management as needed.Serves as the point of contact for Care Management to communicate with practice.9) Participates on a team for data collection, health outcomes reporting, clinical audits, and programevaluation related to the Quality Improvement metrics/measures as needed forNCQA/Payor/Nemours. Assists with the identification of areas for improvement within theirpractice. Reviews Navinet and assists with action around gaps and opportunities to meet riskrequirements.10) Creates and promotes adherence to a care plan, developed in coordination with the complexpatient/family, care management team and primary care provider. Works closely with inpatientNurse Case Managers for discharge needs- hospital and NICU11) Monitors specialty consults and follows up if patient/family did not follow through with theappointment or the consult report was not received by the PCP. Helps connect families to specialtyappointments.12) Works with DCHN practices with patient and family to facilitate access to the most appropriate care;reducing emergency room utilization and unplanned hospital admissions/readmissions. Educationaround hospital follow up in collaboration with Nemours Care Managers.13) Educates DCHN practices regarding Care management and assists with care management referrals.14) Coordination of Durable Medical Equipment needs and assists with Letters of Medical Necessity.Completes Asthma Medication Ratio Reconciliation.15) Works with DCHN practices to lead process/workflow change to improve compliance.Bachelor's degreeBSN preferredCurrent unrestricted DE nursing licensure requiredMore than 3 years relevant experienceAbout Us:As one of the nation's premier pediatric health care systems, we've made a promise to do whatever it takes to prevent and treat even the most disabling childhood conditions. It's a promise that extends beyond our nationally recognized clinical treatment to an entire integrated spectrum of research, advocacy, education, and prevention.Equity, diversity, and inclusion guide our growth and strategy. We are looking for individuals who are passionate about, and committed to, leading efforts to provide culturally relevant care, reducing health disparities, and helping build a diverse and inclusive environment. All Nemours Associates are expected to ensure that these philosophies are embedded in their day-to-day work with colleagues, patients and families.Nemours aspires to have its workforce and providers reflect the rich diversity of the communities we serve. Candidates of diverse backgrounds, race and ethnicity, religion, age, gender, sexual orientation, and those committed to working with diverse populations and conversant in multicultural values are strongly encouraged to apply. Please click here to review .To learn more about Nemours and our commitment to treat every child as if they were our own, visit us at .About the Team: At Nemours, Nursing is more than just a department, it is a philosophy embodied by every Nursing Associate - that we are shared guardians of children's health and joy. Our nurses have a gift for caring for children and the needs of their families.Our nurses support an environment of opportunity for personal growth and professional development, teaching each other, and our patients and families important aspects of care.Throughout Nemours, in our hospitals, specialty care clinics, and in outpatient and inpatient settings, our nurses use their expertise and knowledge to translate research into evidence-based practice, continuously improving the safety and quality of our family-centered care.
