Registered Nurse (RN) Patient Care Coordinator - VIVID Health

Discover Vanderbilt University Medical Center: Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research. Organization: SGM Job Summary: JOB SUMMARY: Vanderbilt is a national leader in LGBTQ adult patient care, including cultural competency training, research and education. VIVID Health promotes physical, mental and spiritual well-being for adults of all sexual orientations and gender identities. Our team offers inclusive and compassionate health care and support for the adult LGBTQ community. Our goal: a safe, welcoming place to find resources to live a life that’s healthy and fulfilling. We provide primary care, hormone therapy, surgical consults and other transition-related health care for adults, delivered by a culturally competent and affirming team. This position supports our transgender patients that are serviced in the Primary Care and Plastic Surgery Clinics and is fully funded by VIVID Health. Assists in developing and meeting key Pillar outcomes and system improvement goals including financial, satisfaction, and clinical as the nursing component of the care coordination model. This position Improves outcomes by reducing all cause hospital readmissions and coordinating episodes of care among patients in a defined population or disease process. Participates in identification of appropriate patients; encourage patient and family engagement in self-care management; promote warm handovers to the next level of care by providing timely, pertinent information in a standardized way; conduct patient and family education on key elements of the patients' personal care plan by using the "teach-back" methodology and follow up phone calls; and assists the patient in navigating the healthcare system. . KEY RESPONSIBILITIES • Coordinates the evaluation process of the defined patient population. May complete and document portions of the evaluation process, collaborating with other team members to ensure completion of all required information. • Supports patient access by serving as a liaison between the referring provider's office and Vanderbilt provider. • Interacts routinely and effectively with the clinical team to develop a collaborative plan for the coordination of patient care from the anchor hospitalization through the defined care episode. • Develops and manages the processes related to pre-admission and post-discharge care transitions; establishes relationships/clinical pathways with providers/agencies to optimize care for defined patient population. • Assists in the development and dissemination of patient education materials/information to include creation of customized medication grids with input from the pharmacist/team as needed. • Assists with discharge/transition planning in collaboration with the multi-disciplinary team, actively engaging outpatient care providers by sharing hospital course, concerns, pending test results, learning needs, partnership opportunities etc. Coordinates handovers including outpatient care coordinators (disease management teams), home health care nurses, cardiac rehab, skilled nursing facilities, etc. • Demonstrates reflective practice by constantly evaluating care coordination and supports the development of protocols for practice based on evidence • The responsibilities listed are a general overview of the position and additional duties may be assigned. TECHNICAL CAPABILITIES • Evidence-Based Practice (Advanced): Recognizes, Implements, and evaluates practice changes based on published research. Demonstrates expertise in applying evidence-based practices to challenging and complex situations. • RN Access Patient Education (Advanced): Demonstrates uppermost levels of patient education in practical applications of a complex nature. Possesses mastery of knowledge, training, and expertise to be capable of successfully delivering treatment planning services across the care continuum. Takes a lead role in complex situations when there is a need to achieve results. Actively participates in outside professional organizations and forums. • Nursing Patient Assessment & Evaluation (Advanced): Demonstrates the uppermost levels of expertise in patient assessment and evaluations in challenging and complex situations. Conducts primary care patient interviews and physical examination. Often takes a lead role in complex patient care situations. Possesses expert knowledge, training and experience to mentor less experienced peers. • Trend Analysis (Intermediate): Demonstrates mastery of trend analyses. Can recognize the impact and take into consideration the effect of seasonality and randomness. Has analyzed trends in detecting patterns that could lead to future problems and in forecasting future demand periods. Has worked in several areas that might include sales, marketing, quality, finance and manufacturing. Our Nursing Philosophy: We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center’s mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being. As a Vanderbilt University Medical Center employee, you make a difference to our patients and their families by bringing compassion and care to those in need of hope and healing. Please see our current employee benefits offered: Affordable High Quality Health Plan Options Dental and /or vision plan 403 (b) retirement plan Paid Time off (flex PTO) Tuition Reimbursement and adoption assistance (maximums applied) Short-Long term disability Subsidized backup childcare And many more... Ask us about our current inpatient nursing supplemental Pay Program! Achieve the Remarkable: Learn more about VUMC Nursing: Nursing Careers: http://www.vumcnursingcareers.com/index.html Benefits: http://www.vumcnursingcareers.com/benefits.html Our Nursing Philosophy: http://www.vumcnursingcareers.com/philosophy.html Our Nursing Leadership: http://www.vumcnursingcareers.com/leadership.html Shared Governance: http://www.vumcnursingcareers.com/shared-governance.html Education& Professional Development: http://www.vumcnursingcareers.com/professional-development.html Life In Nashville: http://www.vumcnursingcareers.com/nashville.html VUMC Nursing: http://www.mc.vanderbilt.edu/root/vumc.php?site=vanderbilt-nursing Core Accountabilities: Organizational Impact: Delivers projects/assignments that have a direct impact on goals/objectives of the unit/department that the job is in. Problem Solving/ Complexity of work: Conducts extensive analysis of situations or data to resolve numerous, complex issues; may involve the input/work of others. Breadth of Knowledge: Has in-depth level of knowledge within a professional area and working knowledge of other areas. Team Interaction: May lead mid-sized projects; coaches and guides team members. Core Capabilities : Supporting Colleagues: - Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas. - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships. - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Service: - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them. - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions. - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure. - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area. - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation: - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches. - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges. - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements. Position Qualifications: Responsibilities: Certifications: LIC-Registered Nurse - Licensure-Others Work Experience: Relevant Work Experience Experience Level: 5 years Education: Bachelor's Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and to the principles of equal opportunity and affirmative action. EOE/AA/Women/Minority/Vets/Disabled PEOPLE ARE AT THE HEART OF ALL WE DO. Our vision: The world leader in advancing personalized health. Our mission: personalizing the patient experience through our caring spirit and distinctive capabilities. Making Health Care Personal. We’re looking for like-minded individuals driven to make a difference. We invite you to explore careers at Vanderbilt University Medical Center. At VUMC, we place a priority on designing with and for our patients and families. We value collaboration, embrace continuous learning and discovery, and intentionally pursue diversity and inclusion. These are our guiding “Strategic Directions.” We’re the largest private employer in Middle Tennessee, with a growing team and expanding footprint in towns and communities across the region. We employ more than 28,000 people who work in inpatient and outpatient clinical care, research, and graduate medical education as well as critical supporting roles in administration, information technology and informatics, finance, legal and community affairs, communications and marketing, fund-raising, groundskeeping and facilities, and many more. Our growing health system has a total of 1,615 licensed hospital beds at: Vanderbilt University Hospital Monroe Carell Jr. Children’s Hospital at Vanderbilt Vanderbilt Psychiatric Hospital Vanderbilt Wilson County Hospital Vanderbilt Bedford Hospital Vanderbilt Tullahoma-Harton Hospital It’s also home to hundreds of outpatient clinic and surgical locations throughout the region. We serve our community with many unique and specialized services including the Level 1 Trauma Center, a highly experienced Transplant Center that does the most heart transplants in the world, a National Cancer Institute-designated Comprehensive Cancer Center, Lung Institute, Burn Center and many more. World-leading academic departments and centers make scientific discoveries, advance clinical care and train the next generation of health care professionals. Our robust research enterprise ranks No. 9 in the country as measured by peer-reviewed grant funding from the National Institutes of Health. We’re honored to be consistently considered among the nation’s best hospitals, including being nationally ranked in multiple medical specialties for treating the most complex conditions in adults and children by US News and World Report. The Children’s Hospital ranked as the No. 1 children’s hospital in the southeast in 2021. We support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at VUMC for professional growth, appreciation of benefits, and a sense of community and purpose — never stronger than during the challenging COVID pandemic. Join us in Making Health Care Personal.