RN Patient Care Coordinator
Manage and coordinate care for 300 patients, conducting Chronic Pain, Post Hospital and other assessments to prevent hospital readmission. Work one-on-one with patients to evaluate, educate, and motivate in understanding disease process, making lifestyle changes, managing medications & communicating w/ MDs.
- Achieved >90% of clinical goals and consistently generated improved health outcomes by educating and empowering patients in effective at home disease management.
- Earned 105% engagement rate by creating trust and rapport with patients and adopting Information- Motivation-Behavioral (IMB) Model to successfully pinpoint and shift core obstacles to change.
- Reduced hospital readmissions to .01% by using comprehensive process combining clinical, financial, and psychosocial approach to identify trends and early indicators, resolve barriers, and create strategy ensuring appropriate service/resource utilization by chronically ill patients.
- Attained 94% medical record completion rate, 2nd highest on team of 30 nurses, by employing highly effective interviewing techniques and meticulous oversight of reporting processes.
- Identify need for chronic case management, social work, and/or behavioral health care services, making interagency and interdepartmental referrals as necessary.
- Receive 10-15 patient success stories per month chronicling major improvements in health.
- Analyze financial and logistical barriers to at home care and assist patients in resolving.