Position Overview: The Care Coordination Program at CareMount Medical enables patients to be treated in an environment combining an expert medical team with individual attention and compassionate care. The Care Coordinator empowers patients to actively participate in improving their own healthcare through personalized care that targets each patient's specific healthcare issues and needs. The Care Coordination Discharge Coordinator Nurse role is focused on reduction in Hospital readmission rates and use of the emergency department, based on determined ambulatory sensitive conditions. The Discharge Coordinator Nurse, in partnership with our Embedded Care Coordination RNs, performs essential, proactive, patient centered care to patients and their families during their acute care episode from various inpatient settings (ie. hospital, SNF, Rehab, ER) to ensure patients and their families understand the discharge care plan and work to facilitate appropriate follow up, both long and short term, with the goal of reduction in health care cost and utilization. The Care Coordination Discharge Coordinator Nurse is an integral part of CareMount Medical care team 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 Discharge Care Coordination Nurse is an integral member of the direct delivery care team, and serves as a gateway to information and support. The Discharge Care Coordination Nurse (LPN) performs daily communication with the acute care team, the Embedded Care Coordination RN, the PCP office care team, the patient and caregivers to ensure optimal communication and care, both during and after the acute care episode. The patient communication goal is to facilitate understanding of the hospitalization, the discharge care plan and assess patient literacy of same.

The Discharge 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 during the hospitalization, including:

Assess patient and family's unmet health and social needs

Provide effective communications to improve health literacy

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.

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

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

Facilitate communication between specialists and Primary Care Physician post-discharge for development of cohesive care plan, communicating action items to all responsible parties and following up to completion of same.

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 Licensed Practical Nurse (LPN) 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