Work where every moment mattersEvery day over Hartford HealthCare colleagues come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkHartford Hospital is one of the largest and most respected teaching hospitals in New England We are a Level Trauma Center that provides cutting edge treatment to its patients This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education Simulation and Innovation CESI one of the most advanced medical simulation training centers in the world When hospitals cannot provide the advanced care expertise and new treatment options their patients require they turn to usThe Adult Primary Care APC clinic is located at Jefferson St Hartford Hospital APC Clinic has over patient visits annually with an average of patients per day We are a busy outpatient ambulatory care clinic setting at a teaching hospital We see patients for preventative annual care as well as patients with a wide range of health problems such as diabetes high cholesterol asthmaCOPD and hypertension Staffing includes attendings APRNs Residents Psychologist Social Worker Nutritionist Pharm D RNs MAs and MAAs APC facilitates an ongoing relationship between patients and clinicians and fosters participation by patients in decision making about their health and their own care The majority of our patients are bilingual with Spanish being their primary language and have health coverage under Medicaid APC provides opportunities for disease prevention and health promotion as well as early detection of problems APC guides patients through the health system including appropriate referrals for services to other health professionals We are recognized as a Patient Centered Medical HomeJob SummaryThe Case Coordinator ndash Outpatient at Adult Primary Care APC participates in an expanded nurse role as an integral member of the primary care team The Case Coordinator works in a collaborative environment with the interdisciplinary team including but not limited to the patient patients family clinic medical team social workers hospital case coordinators hospital complex care team home care agencies focused on a patient centered medical home PCMH care model The Case Coordinator must possess our institutional values of integrity kindness safety nurse excellence leadership and professionalism while providing high quality safe care Under the direction and general supervision of the Nurse Manager the Case Coordinator utilizes evidence based practices in accordance with the State Nurse Practice Act policies and procedures of the hospital and as directed by the medical staff With a goal of reducing readmissions and improving quality of life for patients the Case Coordinator uses expert knowledge and the nursing process to develop a plan of care which includes standards of practice to meet the physical emotional spiritual cultural and educational needs of the patient and family The Case Coordinator provides individualized care implementing interventions including medication education disease process education and on going counseling promotion of self care and adherence to an individualized care plan The Case Coordinator provides information and guidance to the patient andor caregiver resulting in effective care transitions improved self management skills and knowledge of their illness and or disease process in addition to supporting enhanced communication between the patient and the healthcare teamJob Responsibilitiesmiddot Monitor inpatient admissions of APC patients and subsequent discharges assist with transitioning complex casehigh risk patients in collaboration with hospital team PCP home care agencies etc work with interdisciplinary team to review cases and risk stratify inpatients to act upon any identified issues while patient is admittedmiddot Meet patient at the bedside before discharge as appropriate complexhigh risk cases to educate patient on follow up set expectations and discuss services that will be provided by Case Coordinator at APCmiddot Develop a self management action plan of care coordinate services and navigate the patient through the healthcare system with a goal of enabling the patient and family to effectively manage their conditions and optimize outcomesmiddot Attend and engage in team meetings at APC including but not limited to staff meetings Ambulatory Care Operations meetings Readmission Avoidance Committee meetings middot Perform outreach calls post hospitalization for all admitted APC patientsmiddot Assist APC program in implementing Transitional Care Management and Chronic Care Management billing for Medicare patients per CMS billing guidelinesmiddot Partner with PCP and care team clinic nurse social work psych etc for high riskcomplex patient appointments at APCmiddot Be an integral part of the Complex Transition Workflow for transitions fromto APC Hartford Hospital for high riskcomplex patientsmiddot Goals of the position are to reduce readmissions decrease inappropriate ED utilization increase care coordination for patients through the care continuum improve health equity for vulnerable populations educate and advocate for patients to follow patient centered care plans increase collaboration of the care team for high riskcomplex patientsmiddot Identify execute and track needed referrals to care and community servicesmiddot Document all communication with patient and or care team in EPICWork where every moment mattersEvery day over Hartford HealthCare colleagues come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare networkHartford Hospital is one of the largest and most respected teaching hospitals in New England We are a Level Trauma Center that provides cutting edge treatment to its patients This is made possible by being home to the largest robotic surgery center in the Northeast and the Center for Education Simulation and Innovation CESI one of the most advanced medical simulation training centers in the world When hospitals cannot provide the advanced care expertise and new treatment options their patients require they turn to usThe Adult Primary Care APC clinic is located at Jefferson St Hartford Hospital APC Clinic has over patient visits annually with an average of patients per day We are a busy outpatient ambulatory care clinic setting at a teaching hospital We see patients for preventative annual care as well as patients with a wide range of health problems such as diabetes high cholesterol asthmaCOPD and hypertension Staffing includes attendings APRNs Residents Psychologist Social Worker Nutritionist Pharm D RNs MAs and MAAs APC facilitates an ongoing relationship between patients and clinicians and fosters participation by patients in decision making about their health and their own care The majority of our patients are bilingual with Spanish being their primary language and have health coverage under Medicaid APC provides opportunities for disease prevention and health promotion as well as early detection of problems APC guides patients through the health system including appropriate referrals for services to other health professionals We are recognized as a Patient Centered Medical HomeJob SummaryThe Case Coordinator ndash Outpatient at Adult Primary Care APC participates in an expanded nurse role as an integral member of the primary care team The Case Coordinator works in a collaborative environment with the interdisciplinary team including but not limited to the patient patients family clinic medical team social workers hospital case coordinators hospital complex care team home care agencies focused on a patient centered medical home PCMH care model The Case Coordinator must possess our institutional values of integrity kindness safety nurse excellence leadership and professionalism while providing high quality safe care Under the direction and general supervision of the Nurse Manager the Case Coordinator utilizes evidence based practices in accordance with the State Nurse Practice Act policies and procedures of the hospital and as directed by the medical staff With a goal of reducing readmissions and improving quality of life for patients the Case Coordinator uses expert knowledge and the nursing process to develop a plan of care which includes standards of practice to meet the physical emotional spiritual cultural and educational needs of the patient and family The Case Coordinator provides individualized care implementing interventions including medication education disease process education and on going counseling promotion of self care and adherence to an individualized care plan The Case Coordinator provides information and guidance to the patient andor caregiver resulting in effective care transitions improved self management skills and knowledge of their illness and or disease process in addition to supporting enhanced communication between the patient and the healthcare teamJob Responsibilitiesmiddot Monitor inpatient admissions of APC patients and subsequent discharges assist with transitioning complex casehigh risk patients in collaboration with hospital team PCP home care agencies etc work with interdisciplinary team to review cases and risk stratify inpatients to act upon any identified issues while patient is admittedmiddot Meet patient at the bedside before discharge as appropriate complexhigh risk cases to educate patient on follow up set expectations and discuss services that will be provided by Case Coordinator at APCmiddot Develop a self management action plan of care coordinate services and navigate the patient through the healthcare system with a goal of enabling the patient and family to effectively manage their conditions and optimize outcomesmiddot Attend and engage in team meetings at APC including but not limited to staff meetings Ambulatory Care Operations meetings Readmission Avoidance Committee meetings middot Perform outreach calls post hospitalization for all admitted APC patientsmiddot Assist APC program in implementing Transitional Care Management and Chronic Care Management billing for Medicare patients per CMS billing guidelinesmiddot Partner with PCP and care team clinic nurse social work psych etc for high riskcomplex patient appointments at APCmiddot Be an integral part of the Complex Transition Workflow for transitions fromto APC Hartford Hospital for high riskcomplex patientsmiddot Goals of the position are to reduce readmissions decrease inappropriate ED utilization increase care coordination for patients through the care continuum improve health equity for vulnerable populations educate and advocate for patients to follow patient centered care plans increase collaboration of the care team for high riskcomplex patientsmiddot Identify execute and track needed referrals to care and community servicesmiddot Document all communication with patient and or care team in EPICmiddot BSN MSN preferredmiddot Five years nursing experience One year of the nursing experience in ambulatoryoutpatient setting preferredmiddot Current CT RN licensemiddot BLS Certificationmiddot Expected to obtain CCMCCCTM certification within two years of hiremiddot Bilingual Spanish verbal and written strongly preferredWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologiesbreakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this is your momentAs an Equal Opportunity EmployerAffirmative Action employer the organization will not discriminate in its employment practices due to an applicantrsquos race color religion sex sexual orientation gender identity national origin and veteran or disability statusmiddot BSN MSN preferredmiddot Five years nursing experience One year of the nursing experience in ambulatoryoutpatient setting preferredmiddot Current CT RN licensemiddot BLS Certificationmiddot Expected to obtain CCMCCCTM certification within two years of hiremiddot Bilingual Spanish verbal and written strongly preferredWe take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologiesbreakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving employees we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this is your momentAs an Equal Opportunity EmployerAffirmative Action employer the organization will not discriminate in its employment practices due to an applicantrsquos race color religion sex sexual orientation gender identity national origin and veteran or disability status