The RN Care Coordinator provides care coordination, medical and disease education and outreach services to Lurie Children’s Health Partners (LCHPCC) members. This position is a community-based role that will perform visits to members’ homes, schools, physician’s offices, in addition to working from home.
1. Completes Health Risk Assessments, Disease Specific Assessments and Clinical Risk Assessments
2. Identifies care needs and goals based upon:
• assessment findings
• analysis of claims data
• provider input
• LCHPCC member and parent/caregiver expressed goals
• Reviews clinical and social data for every patient.
• Identifies care coordination needs through review of record, participation in rounds, care conferences and clinician/family contact
3. Establishes Care Plan, in conjunction with members, parents/caregivers and key providers. Plan shall identify:
• Essential primary, specialty, and ancillary services and providers
• Needed social support and services and identified community-based organizations that can address those needs
• Educational needs of participant and/or caregivers to enhance self-management
• Appropriate utilization of providers to address psychological, developmental and/or medical conditions
• Potential barriers to meeting goals and plan for mitigating barriers
• Individualized disaster preparedness plan
4. Provides medication reconciliation for assigned members
5. Educates family on member’s conditions, medications, medical treatments and facilitates members and families becoming increasingly independent in the care of the member.
• Works with care team and family to implement care plan
• Provides communication link between all involved in case plan
• Assures coordination of care in collaboration with Medical team
• Collaborates regularly with payors, physicians and other agencies to improve
processes and systems related to care coordination
• Assures communication with physicians, payers, business office and/or other
agencies upon discharge or transfer
• Facilitates transition to next phase of care by serving as liaison between
a. Convenes and facilitates Interdisciplinary Care Team (IDCT) meetings to ensure communication and coordination between CCE participant, parent/caregivers, and key healthcare and support service providers
b. Refers families to resources available to meet identified needs.
c. Advocates consideration of all options available to assure quality of care in the most cost-efficient manner.
d. Facilitates processes to assure patients are cared for in the most appropriate setting along the Children’s Hospital of Chicago Medical Center continuum
e. Works closely with medical team in order to care plan goals and timeframes
8. Monitors clinical and functional status of participants through regular face to face contact and convenes IDCT meetings on an ad hoc basis to address gaps in care or barriers to successful implementation of Care Plan
9. Maintains and ensures the confidentiality of all Personal Health Information (PHI) collected and disseminated, in accordance with HIPAA requirements
10. Provides LCHPCC members and parents/caregivers with education required to care for child in home/community
11. Directs, as appropriate, the Community Health Worker with regard to:
• Scheduling appointments
• Linking participant and family/guardian to community based organizations and services
• Follow up with/support for participant and family/guardian
• Communication with/support for providers
12. Other Responsibilities
a. Adheres to all policies and procedures
b. Maintains strict confidentiality of client, company and personnel information
c. Demonstrates a strong commitment to the mission and values of the organization.Continues professional growth through educational opportunities, professional literature review, or other enrichment aimed at readiness to achieve and/or maintain certification in case management as indicated.
d. Completes annual training to include ADA, Cultural Competency, as well as any additional relevant trainings as assigned
e. Performs other duties as assigned