Continuing Care Coordinator RN
US-AZ-Prescott
commonspirit_careers
Req #: 421547
Type: Day
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Overview: Dignity Health Medical Group (DHMG) is the employed physician group for Dignity Health Arizona, serving as the clinical and academic engine for the entire system. We invite you to join a collaborative team where clinical excellence, education, and compassionate care intersect. DHMG employs approximately 200 providers and 500 support staff, covering more than 73 diverse subspecialty services. Our success over the past few years has led to tremendous growth and expanded opportunities across the state. DHMG is dedicated to preparing tomorrow's healthcare leaders. Our providers play pivotal roles in 25 academic programs, training 84 medical students and approximately 200 residents and fellows. This commitment to education means your clinical services are complemented by opportunities for research, innovation, and scholarly activity, ensuring continuous professional growth. As an integral part of the Dignity Health hospital system, DHMG employees benefit from full access to state-of-the-art facilities and resources across our campuses. This unique integration ensures we deliver state-of-the-art, patient-centered services while remaining committed to our mission of providing care to all, including the poor and disenfranchised. Join us to pursue excellence in clinical care and make a true impact in the community. Responsibilities: As our Continuing Care Coordination RN for Population Health at Dignity Health, you will be a vital part of a team dedicated to improving patient outcomes beyond the hospital stay. You will actively manage a panel of patients, focusing on those with complex needs, chronic conditions, and frequent hospital admissions. Your primary role will be to coordinate care transitions, ensuring a smooth and safe journey for patients from the hospital back to their home or another care setting. You will develop and implement personalized care plans, educate patients on self-management, and connect them with community resources to prevent readmissions and improve their overall quality of life. You will collaborate closely with an interdisciplinary team, including physicians, social workers, and pharmacists. Using a data-driven approach, you'll identify gaps in care and work proactively to address them, ultimately driving better health outcomes for our patient population. * Develops a plan of care based on a nursing assessment of the patient and their individual circumstances. * Participates in development of workflows and audits * Coordinating care across multiple provider sites and interdisciplinary teams * Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program * Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible. Qualifications: Required * Graduate of an accredited school of nursing. * Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience. * AZ RN license Preferred * Bachelor's Degree in Nursing (BSN) * 3 to 5 years of nursing experience.
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