CCI Health & Wellness Services
  • 26-Sep-2018 to 25-Dec-2018 (EST)
  • Gaithersburg, MD, USA
  • Full Time

CCI Health & Wellness Services is a group practice empowering patients to partner with staff for an unparalleled healthcare experience.  Through integrated teams in a learning environment, we deliver high quality affordable care to every patient during all stages of life.


The Registered Nurse Care Coordinator, under the direction of the Nursing Director, has primary responsibility for care management activities for a site specific patient panel at CCI Health and Wellness Services.  This includes identifying the high acuity patient population and developing, conducting, and monitoring care management processes as part of the Patient Centered Medical Home. The Registered Nurse Care Coordinator (RNCC) works cooperatively with staff, providers and site leadership triad (Health Center Medical Director/Officer, Nursing Director, and the Health Center Manager) and Administration.  She/he helps coordinate care, services, and resources for chronically ill and medically complex patients to facilitate improved outcomes.  The RNCC helps patient identify goals, needs and resources, and together, formulate a plan to meet those goals through coordinated services, resources and providers.  

As a member of the health center's integrated care team, the RNCC fulfills the following KEY FUNCTIONS AND RESPONSIBILITIES for the provision of patient centered, coordinated care:

  • Manages the flow of the clinical team's daily schedule, including leading or participating in team huddles, identifying patients presenting with complex medical problems, who may need additional assistance such as care management or other, and assisting the provider-MA teams in the provision of quality comprehensive patient care.
  • Actively manages assigned empanelment of high acuity, chronically ill and medically complex patients in the following manner:
    o Provides leadership and case management for clinical social work, utilization management and discharge planning.
    o Collects and reviews information about the client's health and medical history, level of functioning, behavior, mental health, cognition, environment, finances, and formal and informal support systems.
    o Assumes oversight of the daily operations of the Care Management Program, and represents nursing department and CCI Health and Wellness Services to internal and external customers. This includes patients and families, nurses, medical care providers, ancillary medical personnel, service line leadership, including quality care and population healthcare managers, administration, hospitals, health plans, and other third-party payors.
    o Assists Clinical Directors with systems, processes, outcome of clinical care teams, and programs designed to address clinical, psychosocial and financial needs of patients and families.
    o Generates i2i lists that target specific pre-determined criteria for enrollment in Care Management.
    o Additional responsibilities include; personnel management of a multidisciplinary team, regulatory compliance, collaboration across CCI Health and Wellness Services and organization, safety and risk management, performance improvement, staff education and policy implementation.
    o Develops relationship with patients as an integral member of the clinical team.
    o Works with patients and patient care team(s) to coordinate changes readiness and needs assessments.
    o Develops an individualized treatment care plan in coordination with patient and primary care team.
    o Assists patients in setting SMART (Specific, Measurable, Achievable, Realistic and Time bound) goals for self management, teaching them how to do self-management tasks and reports abnormal findings to their primary care team.
    o Collaborates with the patient, physician, and other care team members in assessing the patient's progress toward individual healthcare goals.
    o Coordinates care plan documentation to develop a baseline for tracking, accountability, and quality measurements; develops steps required in achieving the agreed upon goals.
    o Assesses barriers when patient has not met treatment goals, is not following plan of care, or has not kept important appointments.
    o Provides follow-up contact with patient as indicated to ensure compliance with recommendations medications, lab/x-ray, specialist visits, Primary Care Provider (PCP) visits, dieticians, Certified Diabetic Educator, other consults, etc.
    o Anticipates the needs of the patient population, completes necessary documentation and pre-visit planning, addresses areas of concern, and requests for patient's pertinent records prior to visit.
    o Collaborates with payor Care Managers for additional services when appropriate
    o Develops a list of medical supply and community resources available to patients; maintains collegial relationships with the entities used.
    o Plans, coordinates and presents weekly rounding meetings to promote teamwork and care coordination among internal stakeholders.
  • Documents accurately and comprehensively, based on the standards of practice and current organization policies.
  • Works with consulting physicians, hospitals, ER and other frequently used healthcare resources to clarify roles, and develops effective, efficient, timely communication between PCP and these entities.
  • Collaborates with, and provides guidance to Community Health Workers as part of the overall care management process.
  • Assists in developing care management workflow for CCI Health and Wellness Services' staff, including recommended guidelines for referral to care management, and communication practices with primary care team.
  • Works effectively with all clinical teams as a resource, and assists in the development, procurement, and adoption of patient self-management educational resources used by the primary clinical teams, including:
    o Development of pre-visit planning workflow, to ensure efficiency of care, prior to visit whenever possible.
    o Reviewing after-visit summary with patients whenever appropriate.
    o Teaching and involving patients in activities to promote interest in self-care and improve health condition.
    o Providing instructions on self-management tasks that patient can perform in order to gain greater control of health status.
  • Promotes and fosters an atmosphere of teamwork and excellence among staff.
  • Participates in Performance Improvement activities as needed.
  • Leads by example to provide Center-wide high quality care that is patient centered, and meets CCI Health and Wellness' established standards.
  • Regularly conducts Quality Improvement staff meetings to discuss issues and corrective measures to meet goals.
  • Assists in developing methods for monitoring patient outcomes for those enrolled in care management. Continues reassessment of client's status and satisfaction with services rendered in order to evaluate progress toward goal achievement; determine need for further services and makes adjustment to care plan.
  • Discontinues services when client no longer needs or desires services, or becomes ineligible for services, and documents discharge plan in client's record.
    Supports CCI Health and Wellness Services' mission and goals.

Minimum Skills, Experience and Educational Requirements:

  • Ability to implement, monitors, and manage requirements within the primary care setting. Professional nursing skills required include but are not limited to the following:
  • Critical thinking and patient assessment.
  • Problem analysis and proposal of resolution based upon available resources.
  • Leadership abilities, collaboration with multidisciplinary teams and strong communication skills.
  • Occasional bending.
  • Occasional lifting, pushing and/or moving up to 25 pounds.
  • Operating computer including keyboard and multi-line phone.
  • Working in excess of 8 hours per day or 40 hours per week as needed.
  • Written and oral fluency in English and Spanish preferable (Preferred)
  • Proficient in computer skills.
  • Knowledge/experience with Electronic Medical Records (EMR) (Preferred)
  • Minimum of three (3) years of Registered Nursing practice, including 1 year as patient care coordinator.
  • Experience in provision of Primary Care with medically underserved populations is highly desirable
  • Ability to organize, solve problems, multi-task, and work well in a high-pressured atmosphere.

Required Certifications and Licenses:

  • Associate or Bachelor of Science in Nursing
  • Licensure in the state of Maryland
  • CPR (classes are regularly provided at CCI)
CCI Health & Wellness Services
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