RN Care Coordinator - Primary Care TheARC

Children's Health Centers work with community partners to help build healthy neighborhoods. Through outreach programs and advocacy, we can identify specific community needs and continue to serve our youth in critical health areas such as asthma, mental health, substance use, obesity and sexual health.

Our Centers are the largest providers of pediatric primary care services in Washington, D.C. We are proud to offer community-focused, culturally competent care. We work to build healthy communities by delivering care through our health centers, clinics and mobile health services.

Position Summary

The Care Coordinator will systematically review data and collaborate with all involved teams and support services to ensure that patient and family needs are met during inpatient hospitalization or in outpatient/ambulatory setting. Identifies and prioritizes clinical and psychosocial goals throughout inpatient stay or in the outpatient/ambulatory setting; problem-solves as needed to ensure follow-through with multidisciplinary team. Ensures optimal inpatient or outpatient coordination, excellent collaboration between teams, with a focus on family experience and outcomes.

Minimum Education
BSN (Required)

Minimum Work Experience
At least 3 years inpatient/outpatient nursing experience (Required)

Experience with care coordination and evidence of leadership within multidisciplinary teams. (Preferred)

Required Skills/Knowledge
Excellent communication skills required. Ability to work with diverse groups. Ability to de-escalate difficult situations and perform service recovery as needed. Knowledge of clinical processes and hospital procedures for admission, inpatient stay, transfer, discharge and/or outpatient/ambulatory setting.

Required Licenses and Certifications
Registered Nurse (Required)

Basic Life Support for Healthcare Provider (BLS) (Required)

Functional Accountabilities:
Professional Practice/Research

• Identifies patients/families for Care Coordination services in a systematic manner.

• Completes ongoing staff education regarding coordination of care, culturally sensitive care, compassion fatigue, and other relevant topics.

• Integrate evidence-based practice and research into care delivery

Structural Empowerment

• Follows through on any service needs or requests until complete and satisfactory resolution; updates the team as needed.

• Supports unit-based and/or outpatient family activities and education to improve healthcare outcomes including but not limited to PICU support groups.

• Assists in prioritizing need for inpatient and/or outpatient support services e.g. Concierge, Nurse Navigator, Language Services, Lab, Radiology and Regional outpatient locations.

Exemplary Professional Practice

• Completes documentation of all relevant conversations, meetings, and referrals.

• Rounds daily and escalates any family concerns or needs to the appropriate person or service.

• Orients families to the PICU environment.

• Collaborates with Pharmacies (Specialty and Local) for medication adherence (if applicable)

New Knowledge, Innovations, and Improvements

• Participates in safe sleep rounds for identified infants in the unit and initiates other safety-based training as needed e.g. Family and Friends CPR.

• Sends regular updates to the leadership team regarding family support and patient status.

• Use the nursing process in the clinic setting and in Telehealth services to assess patient problems and concerns; critically analyze and integrate subjective and objective data (if applicable)

Leadership

• Updates team members as frequently as needed to ensure "one voice" consistent communication to families.

• Acts as a liaison among clinical services e.g. Inpatient teams, multidisciplinary teams, surgical teams, and between clinical services and support services e.g. social work, case management.