The Permanente Medical Group, Inc. (Kaiser Permanente Northern California)
Fresno & Modesto, California
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Under general supervision, the RN Care Coordinator (RNCC) is responsible for facilitating and coordinating the care delivered to an assigned group of patients through multidisciplinary and patient/family collaboration to ensure quality and cost-effective outcomes are delivered within appropriate care coordination parameters. Coordination involves assessment, planning, support, and evaluation of patient care and related outcomes. Activities to be performed are facilitation of appropriate status and level of care, screening for high risk and transition of care needs, interviews with patient/family, and progression of care facilitation with the healthcare team. Encounters occur face to face, telephonically, and electronically with patients in clinic, at home, at school, and at work. Is an active contributor in the development of systems (e.g. care maps, clinical paths) to improve the care of assigned patient populations. Helps ensure compliance with state, federal and third-party payor requirements.
Essential Functions:
Uses Nursing Process to Create patient and family centered goals and plans Establish and maintain patient and family centered relationships Collect assessment data relating to patient health needs and concerns. Analyze assessment data to determine patient and family needs. Work with patient and family to identify goals and outcomes. Develop evidence-based interventions and care plans to support goals and outcomes. Implement plan with patient, family, care team. Conduct systematic and timely evaluation of outcomes of nursing care and care plan. Document care according to organizational standards, contractual and regulatory requirements, state and federal laws. Encourage preventative care. Assist and educate patient and caregivers. Support patients and caregivers in developing skills to promote, maintain and restore health. Review and educate patient and caregivers on medications and treatments. Incorporate cultural humility, language appropriateness, health literacy, and preference into patient care, care plans and communication. (40%)
Care Management Work within and in support of the health care team to coordinate the delivery of care within the clinic setting, throughout the organization, and across healthcare settings. Delegate appropriate intervention to care team members based on scope, competency, state practice act, standard work and organizational policies. Provide information to the healthcare team, including patient and family regarding resources and benefits to support safe transitions and timely provision of healthcare services. Advocate to secure benefits for patient and identify potential barriers to payer coverage. Serve as point of contact with the patient and among healthcare services and organizations. Coordinate community resources. Provide care management to appropriate patients and according to organizational policies and payer guidelines. (40%)
Professional Practice and Collegiality Flexible and accommodating to patient, clinic setting, community, payer, and organizational needs. Attain and maintain knowledge and competency to reflect current evidence-based nursing practice. Proactively assess needs of others: care team members, patients, and families. Contribute to positive, supportive, healthy and inclusive work environment through positive interactions, respectful communication and creative solutions. (20%)
Education:
Associate's Degree Completion of a nursing education program that satisfied the licensing requirements of the Colorado State Board of Nursing for Registered Nurses. Required
Work Experience:
1-3 years clinical experience in a hospital, acute care, home health/hospice, direct care or case management required. Required
Licenses:
RN-Registered Nurse - DORA - Department of Regulatory Agencies Required and
BLS-Basic Life Support (BLS/CPR) - AHA - American Heart Association Required
Knowledge, Skills and Abilities:
Bilingual in English/Spanish preferred.
Knowledge and understanding of case management/coordination of care principles, programs, and processes in either a hospital or outpatient healthcare environment.
Effectively collaborate with and respond to varied personalities in differing emotional conditions, and maintain professional composure at all times. Strong customer service orientation and aptitude.
Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action.
Ability to communicate verbally and in writing complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
Proficient in Microsoft outlook, Word, and Excel
Experience with electronic health records and documentation of care coordination services preferred.
Shift
Days (United States of America)
Work Type
Regular
Salary
$79,500.00 - $123,200.00 / yr
Benefits
At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future - with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development - while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you.
Here is a small list of our benefit programs:
Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
100% paid parental leave up to 6 weeks
Immediate eligibility for retirement plans with employer contribution up to 9.5%
Generous medical, dental, vision plans in addition to employer paid disability and life insurance.
Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center
Free RTD EcoPass (public transportation)
Childcare discount programs & exclusive perks on large brands, travel, and more
Tuition reimbursement & assistance
Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
Professional clinical advancement program & shared governance
Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer
About Denver Health
Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation.
As Colorado’s primary, and essential, safety-net health care system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year.
Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation's leaders in medicine.Denver Health is an Equal Opportunity Employer At Denver Health we pride ourselves on our commitment to diversity. Equal opportunity is a fundamental principle of Denver Health. As an equal opportunity employer, Denver Health is committed to recruit, hire, promote and administer all human resource actions in a non-discriminatory manner. Denver Health is committed to providing equal opportunities in all business practices and to all persons regardless of age, race, color, national origin, genetic information, religion, sex, pregnancy, disab...ility, sexual orientation, gender identity, gender expression, marital status or veteran status (collectively “protected status”). Denver Health strives to maintain a work environment that is free from unlawful harassment and discrimination and will not tolerate any such conduct by employees or directed at employees within the scope of their employment. Read the full Human Resources Employee Principles and Practices policy.