Position Overview: The Care Coordination Program enables patients to be treated in an environment combining an expert medical team with individual attention and compassionate care. The Embedded Care Coordination Nurse empowers patients to actively participate in improving their own healthcare through personalized care that targets each patient's specific healthcare issues and needs. S/he coordinates with other members of the care team to ensure seamless care delivery, maximal coordination of efforts, and active patient participation in planning and care. With the support of an Embedded Care Coordination Nurse, patients with chronic illnesses are able to improve their health condition, adhere to treatment plans, and ultimately avoid costly hospital readmissions or visits to emergency departments. They can help patients keep their independence while dealing with an illness or injury. The Embedded Care Coordination Nurse is an integral part of CareMount and our approach to delivery of patient-centered, compassionate, medical care, complementing the necessary professional services to patients.

Essential Duties and Responsibilities (including but not limited to the following):

*The Embedded Care Coordination Nurse is an integral member of the direct delivery care team, and serves as a gateway to information and support; Actively participates in the care team to ensure that patient needs and preferences are incorporated into the comprehensive plan of care.

*Demonstrates a proactive approach to patient care, focusing on addressing each patient's individual and family needs at the time of service; communicates identified needs in a timely manner.

*Utilizes evidence-based approaches with patients/families/caregivers to support self-management, self-efficacy, and health-promoting behavior change.

*Using population-specific knowledge and clinical expertise, contributes to the continual assessment and effective management of the health needs of assigned patient populations.

*Demonstrates effective communication strategies reflective of the needs of all patients, including those from vulnerable populations

*The Embedded Care Coordination Nurse utilizes tools and documents that support a guided care process, collaborating with patients/families/Physicians and other members of the care team toward an effective plan of care, including:

1.Assess patient and family's unmet health and social needs

2.Provide effective communications to improve health literacy

3.Develop a care plan based on mutual goals with patient, family and provider's emergency plan, medical summary and ongoing action plan, as appropriate. Monitor patient's adherence to plan of care and progress toward goals in timely fashion, facilitate changes as needed.

4.Communicates potential for additional care coordination with outside organizations and/or providers when identified

*Facilitate transitions of care for patients from acute stays or sub-acute rehab stays to home or long term care facilities.

*Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists.

*Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow up, integration of information in to the care plan regarding transition of care and referrals.

*Ensure effective tracking of test results, medication management and adherence to follow-up appointments.

*Attend and actively participate in care coordinator related training and meeting activities.

*Perform regular visits to provide patient and family support and education.

Qualifications and Education:

*Must be a registered nurse (RN) in New York State
*3-5 years' experience in clinical or community health settings, preferred
*Previous experience in caring for chronic disease patients, required
*Previous care Coordination, case management or Home Health experience, preferred
*Experience with navigation of local medical and social support systems,
*Previous experience with Electronic Medical Records and Microsoft Excel, preferred.

Knowledge, Skills and Abilities:

*Knowledge of community health services and willingness to develop and foster relationships with community resources of direct value to CareMount Medical patients and care team.
*Strong organizational skills and demonstrated the ability to maintain accurate notes and records.
*Strong interpersonal skills and an understanding and commitment to delivery of patient centered medical care with a team-based approach
*Ability to work independently, exercise creativity, is attentive to detail.
*Ability to manage multiple and simultaneous responsibilities and to priorities scheduling of work autonomously

All qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status. CareMount is an EO employer - M/F/Veteran/Disability