Complex Care Coordinator RN Community Health and Advocacy

SUMMARY

The Complex Care Coordinator - RN manages a panel of patients identified as high-risk for meeting complex and/or chronic criteria to ensure comprehensive care is coordinated. The CCC, Nursing, promotes seamless care continuity, improved health outcomes, equitable access for the population of focus and comprehensive care considering physical, behavioral, and health-related social needs within time- limited designated timeframe. This position is responsible for managing patients with health care needs that create risk for poor health outcomes due to gaps in care, fragmented or complex care plans, delayed or duplicate treatment, and preventable/unnecessary ED or inpatient admissions. The coordinator ensures that the care provided is patient- and family-centered, evidence-based, fiscally responsible, holistic in nature, and leads to improved outcomes. The coordinator utilizes clinical expertise to drive care coordination efforts for their dynamic panel of patients, in partnership with the multi-disciplinary team.

This position is part of a home visit program focused on supporting children and families managing asthma. The role involves providing home-based asthma education, self-management support, and personalized guidance tailored to each family's needs. While this program does not involve direct clinical care, it offers in-depth education and resources beyond what is typically available in outpatient settings.

Department Name: Community Health and Advocacy
Job Status: part time, 20 hours per week, eligible for benefits
Shift: Variable hours between 8:00 a.m. and 6:00 p.m., Monday-Friday. Schedule may include combinations of 4-5-hour shifts, two 8-hour shifts, and one 4-hour shift depending on patient needs. Some opportunity for remote work will be discussed during the interview process.

This position is eligible for relocation assistance, if relocating from 100 miles or greater.

ESSENTIAL FUNCTIONS

An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the functions which the employee may be expected to perform.

1. Promotes quality, equitable and individualized care by integrating considerations of social determinants of health with comprehensive mental and physical health care plan, ensuring that all patients have access to quality care, optimal health outcomes, and exceptional healthcare experience.
2. Assess, develop, implement, and evaluate a patient's individualized and time limited comprehensive care plan including physical, behavioral, and health related social needs to support patient health goals.
3. Uses data to support the evaluation and improvement of population outcomes in collaboration with leadership.
4. Leads and partners, where appropriate, with interdisciplinary team to identify resources to support the patient and family during care plan implementation and/or health decline to solve identified challenges.
5. Identifies any barriers to the care plan and advocates for patient centered modifications as appropriate.
6. Promotes autonomy of self-management of patient health care through supporting patient needs, education towards care plan and multidisciplinary collaboration.
7. Educates the patient, family, guardian, and/or caregiver to support self-management and promotion of independence minimizing reliance on the health care system where appropriate. Identifies as the primary care coordinator and owns care plan efforts that support improved care coordination through sharing knowledge, acting as role models, and providing clinical expertise.
8. Actively communicates with the patient, caregiver, agencies, and community service providers for the duration of the care plan.
9. Engages with community resources including schools, pharmacies, specialty and primary care teams, and additional community-based partners.
10. Proactively supports treatment adherence by using tools within electronic health record.

MINIMUM QUALIFICATIONS

Education: Bachelor of Science in Nursing (BSN)

Experience: Three years nursing experience

Preferred Experience:

• Experience in asthma or pulmonary health management
• Background in home-based care or community health programs
• Strong skills in patient and family education
• Spanish-speaking preferred

Certification(s): BLS/CPR from the American Heart Association with at least 6 months left before expiration is required upon hire.

Licensure(s): Registered Nurse (RN) licensure in the state of Colorado is required.

Salary Information
Pay is dependent on applicant's relevant experience.

Hourly Range: $40.26 to $60.39

Benefits Information
Here, you matter. As a Children's Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career.

As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April.

Children's Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year.

EEO Statement
It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information. The position is expected to stay open until the posted close date. Please submit your application as soon as possible as the posting is subject to close at any time once a sufficient pool of qualified applicants is obtained.

Colorado Residents: In any materials you submit, you may redact or remove age-identifying information such as age, date of birth, or dates of attendance at or graduation from an educational institution. You will not be penalized for redacting or removing this information.