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RN- Community Health Coordinator
st Chicopee, MA 01013
RN Community Health Care Coordinator
Work with a population of under-served population with medical and psych comorbidities.
Provide initial assessment to observe barriers that prevent patient from managing their own care.
Make recommendations on medication management, adding DME or social work services to care plan-The goal for this role is to keep high risk population from frequent or repeat /ED visits and remain home using their PCP.
- Assists patients with identifying their own strengths and capabilities while assessing the barriers that prevent the individual from following their care plan.
- Provides a high level of patient and family education.
- Day to day, the Case Manager will talk to patients telephonically to discuss the program then schedule an initial home care visitation for patient assessment interview.
- During Comprehensive assessment, you will collaborate with patient and care team to develop patient care plan, focusing on chronic disease management, social determinants, transitions of care
- Once plan is Implemented, provide continuous resource and collaboration with community partners, VNA agencies, DME providers and social service agencies to avoid patient from readmission to ED
- Educates patient on medication and build their self-management skills while using motivational interviewing to promote behavioral change
- Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services.
- Tracks patient' s performance metrics
- Meets regularly with Primary Care, ED, inpatient, and team supervisor, to triage program issues appropriately.
- Care planning in collaboration with pharmacist, social work, peer nurses and housing coordinator
- Registered Nurse in the State of Massachusetts.
- BS in Nursing Preferred
- 5 years Case Management or Home Care or Clinic Nursing experience with patients particularly with Chronic illness and chronic mental health.
- Care plan management or Care coordination experience
- Case management experience in home care or hospital
- Excellent interpersonal skills-verbal and written
- Ability to prioritize and coordinate patient documentation and goals
- Excellent patient education skills
- Excellent EMR documentation skills and other technology skills
- Skilled at engaging difficult to engage patients— build rapport, trust
- Clinical Problem solver
- Excellent knowledge of community health resources
- Strong organizational and time management skills
- Behavioral health or Psych Nursing background also ideal
- No on call or weekends
- GENEROUS PTO and excellent health benefits
- Chicopee/Springfield area
Send resume to Krisha Morander
Director, Healthcare Services & Healthcare IT
Krisha Morander, a Certified Personnel Consultant, (CPC), has over 25 years of experience in the healthcare staffing industry. She also has corporate HR Recruitment, homecare, mental health and academia background to compliment her overall knowledge of hiring talent. Krisha has been continually recognized within our agency for achieving record-high placement activity.
She places all levels of healthcare professionals within a broad spectrum of healthcare organizations across Connecticut and Massachusetts including hospitals, managed care organizations, physician practices, pharmaceutical organizations, mental health, government facilities, and long term care and rehab facilities.
Krisha also complements her searches in the areas of clinical recruitment, information technology and clinical trials & research. The blend of clinical informatics, statistics and analysis are an integrated part of measuring outcomes and data to measure surveys and scores. Krisha continues to stay connected with this evolving and complex industry through her membership with the New England Chapter of Healthcare Information and Management Systems Society (HIMSS).
Krisha majored in marketing with a concentration in Human Resources. Krisha’s industry knowledge, communication skills and passion for recruiting make her an invaluable recruiter here at J. Morrissey.