Overview Catholic Health is one of Long Island’s finest health and human services agencies. Our health system has over 16,000 employees, six acute care hospitals, three nursing homes, a home health service, hospice and a network of physician practices across the island. At Catholic Health, our primary focus is the way we treat and serve our communities. We work collaboratively to provide compassionate care and utilize evidence-based practice to improve outcomes – to every patient, every time. We are committed to caring for Long Island. Be a part of our team of healthcare heroes and discover why Catholic Health was named Long Island's Top Workplace! Job Details The RN Care Coordinator is responsible for oversight and care coordination services for the department’s transition of care, and high-risk, high-cost patients/employees. The RN Care Coordinator ensures a patient-centric care approach, and provides a model of care that ensures the delivery of quality, efficient, and cost-effective outpatient healthcare services to reduce unnecessary emergency room visits and inpatient readmissions. The RN Care Coordinator will work collaboratively with the employees/patients’ health care team to foster optimal outcomes and reduce healthcare costs. Duties and Responsibilities: + Oversees the identification and management of high-risk/high-cost patients/employees + Ongoing communication and collaboration with inpatient, homecare, providers, and community-based organizations to ensure a patient centered care approach and optimal health. + Establishes relationship with employee/patient, identifying and documents goals of care and advanced directives. + Complete patient/employee assessment, care plan, tasks and targets in compliance with established workflow guidelines + Utilizes motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes to achieve optimal health status. + Provides coaching, information and support to empower the member to make ongoing independent healthy lifestyle choices. + Engages and educates patients/employees regarding CH’s health plan benefits in obtaining or maintaining optimal health status + Assesses patient’s readiness to change + Assess and address the gaps in the social determinants of health that may be impacting employee/patient’s health and treatment plan. + Refers to palliative care and hospice when appropriate + Works with Care Manager Coordinator to ensure SDOH’s are addressed + Establishes solid working relationship with ED and Care Management teams in all CH Hospitals + Attends hospital on site rounds, proactive discharge patient review and Readmission meetings as necessary + Attends VBC payer clinical meetings as necessary + Assists when needed with the coordination of care during all transitions within the healthcare continuum. + Reveals ability to work autonomously and be directly accountable for results. + Incorporates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills + Possess the skill to function effectively in a fluid, dynamic, and rapidly changing environment + Displays the proven ability to positively influence behavior and outcomes. + Protects confidentiality of data and intellectual property; ensures compliance with national health information projection guidelines. + Performs duties that may be in an embedded or remote environment. + Serves as a role model for education and professional nursing practice + CH Hospital onsite rounds as needed Position Requirements/Qualifications: + Requires Registered Nurse with current license. CCM or CCTM a plus but not required. + BSN preferred + Bi-lingual Spanish preferred + Minimum of three years recent experience to match responsibilities above such as acute care, home health or skilled nursing facility with a demonstrated working knowledge of VBC.. + Experience as a Care Manager required. + Experience with IT solutions such as electronic health record, learning management or disease/care management systems a plus. + Critical thinking skills and ability to analyze complex data sets required. General computer knowledge and capability to use computers required. + Must meet all productivity standards + Must attend all required meetings remotely and in person as required Salary Range USD $108,000.00 - USD $112,000.00 /Yr. This range serves as a good faith estimate and actual pay will encompass a number of factors, including a candidate’s qualifications, skills, competencies and experience. The salary range or rate listed does not include any bonuses/incentive, or other forms of compensation that may be applicable to this job and it does not include the value of benefits. At Catholic Health, we believe in a people-first approach. In addition to the estimated base pay provided, Catholic Health offers generous benefits packages, generous tuition assistance, a defined benefit pension plan, and a culture that supports professional and educational growth.