Care Coordinator

Registered Nurse Care Coordinator

The Registered Nurse Care Coordinator (RNCC) is responsible for the deliberate organization of patient and family-centered care activities between two or more participants in which the RNCC uses advanced critical thinking to develop, implement, and evaluate individualized care plans to empower patients and optimize outcomes. The RNCC marshals and coordinates resources and patient care activities to support transition management through collaboration across the continuum supporting patient and families' needs for individualized follow-up and coordination of services across healthcare services and locations.

This job profile integrates the ANA Nursing: Scope and Standards of Practice, the ANA Code of Ethics for Nurses with Interpretive Statements, the AAACN Scope & Standards of Practice for Professional Ambulatory Care Nursing, and the AAACN Scope and Standards of Practice for Registered Nurses in Care Coordination and Transition Management with the UVA Nursing Professional Practice Model.

Care coordination and transition management necessitates professional assessment, patient risk identification and stratification, and identification of individual patient needs and preferences. The RNCC:

• Demonstrates the use of the UVA Professional Practice Model through nursing professional practice, quality achievement, lifelong learning, empowered leaders, innovation, and expert caring.
• Plans, coordinates, and prioritizes patient care activities considering patients' unique needs and desired outcomes in collaboration with the inter-professional team, including consult recommendations and escalation as needed.
• Maintains safety and continuity of care using methods such as documentation, hand-off tools/processes, etc.
• Collaborates and advises patients, families, and caregivers in their healthcare decisions, respecting their culture and values.
• Provides health education and coaching to patients tailored to issues identified within treatment and service plans through evidence-based care delivery and safety standards.
• Provides facilitative leadership that promotes health equity across the continuum and among interdisciplinary teams to improve population health, patient experience, and cost reduction.
• Demonstrates knowledge and ability to participate in and apply research and evidence-based practices for the improvement of patient care throughout the lifespan and across the continuum.
• Takes the lead in ensuring the continuity and consistency of care across the continuum to promote and facilitate pre-visit coordination, post-clinic follow-up, and handoff between services along with monitoring and facilitating transitions of care.
• Educates patients & families with chronic illness about evidence-based standards of practice to empower patients to include self-management strategies.
• Identifying support needs and developing action plans and guidance to initiate patient-centered care planning and application of the nursing process.
• Contributes to problem-solving through communication and collaboration and evaluates outcomes of treatment options to include tracking patient progress toward care plans and goals.
• Supports medication management.
• Other duties as assigned.

UVA Nursing Professional Practice Model:

• Relationship Based Care - Self and Colleagues: reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience.
• Relationship Based Care - Patients and Families: reflects the influence of the nurse's relationship with self, colleagues, and patient/family on the patient's experience.
• Expert Caring: encompasses clinical assessment, planning, prioritizing, coordinating, and implementation of care.
• Empowered Leaders: demonstrate knowledge of and actively participate in shared governance.
• Lifelong Learners: encompasses professional development through formal education, professional certification, and internal and external learning opportunities and recognizes the value of external professional organizations. Supports onboarding of new team members and precepts as applicable.

Minimum Requirements:

• Education: Bachelor of Science in Nursing from an accredited nursing program.
• Experience: 1 year of registered nursing experience required; 3 years of related and relevant registered nursing experience strongly preferred.
• Specialty Board Certification strongly preferred.
• License/Certification: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia. American Heart Association (AHA) Health Care Provider BLS certification is required.