PT Pediatric RN Case Manager
The Coordinating Center is a mission driven organization with 36 years of experience in providing care coordination services for people with disabilities and the most complex needs. Our statewide nonprofit serves 10,000 individuals statewide and employs more than 300 coworkers, including Registered Nurses, licensed Social Workers, Community Health Workers, and Supports Planners. Office headquarters are located in Millersville, centrally located and equal distant from Baltimore, BWI Airport and Annapolis.
VIPKids (Very Important Physicians and Kids) is a new medical home program at The Coordinating Center for children and youth with special health care needs (CYSHCN) and their families. In the initial year of development, The Coordinating Center will partner with two or more pediatric practices to deliver care coordination services to the target population. The goal of VIPKids is to develop shared care plans with the family and pediatrician and assist families with accessing resources. By participating in VIPKids, pediatricians will report less time spent on non-reimbursable time, and more time focused on medical management. This is a one-year, grant-funded position with a high likelihood of renewal.
The R.N. Care Coordinator is a part-time, licensed health care professional who provides care management services for children and youth with special health care needs and their families. VIPKids participants are referred by participating pediatric offices who have agreed to partner with The Coordinating Center. The R.N. Care Coordinator is a key member of a multi-disciplinary team responsible for providing care coordination to the target population. This position supports the team by reviewing all referrals that come from participating pediatric practices. This position helps identify the overarching goal of the family, addresses barriers to care, develops a shared care plan, and works with the family to identify and access appropriate resources to address gaps. The R.N. Care Coordinator works closely with Outreach and Resource Specialist in identifying appropriate community resources to meet the child/youth and family needs. The R.N. Care Coordinator promotes health care transition for youth who are of transition age, and provides age appropriate resources. The R.N. Care Coordinator also responds to alerts generated by Maryland’s Health Information Exchange, CRISP for a subset of children/youth who are high risk of repeat hospital use.
The multi-disciplinary team works out of The Coordinating Center’s Millersville location and delivers services telephonically and periodic in-person at a member’s home, a healthcare facility and other locations in the greater Baltimore area as determined by the member and the team.
- Provide individual assistance and support to parents of CYSHCN regarding health care strategies and community resources.
- Provide care coordination across care settings, helps individuals and families/caregivers play an active and informed role in care plan design and execution.
- Promote shared decision making to develop person-centered goals and a shared care plan.
- Uses motivational interviewing techniques when communicating with families to address health disparities and barriers to care.
- Promote timely access to care and connections with community resources.
- Screen all referrals for health care transition readiness and provides education and resources to promote effective health care transition from adolescence to adulthood.
- Provide trainings to participating pediatric practices related to CYSHCN (e.g. health care transition, public funded programs for children, etc).
- Responsible for reviewing and responding daily to CRISP ENS alerts for a subset of referrals based on risk level as identified by the pediatrician.
- Participate in the Medical Home Think Tank to strengthen the VIPKids Program.
- Assist with data collection and interpretation of the data to generate reports.
- Bachelors of Science degree in nursing (minimum), Master’s degree is preferred.
- CCM certification is preferred and is required within two years of the date of employment at The Center.
- Strong motivational interviewing skills
- Strong critical thinking skills to determine identified issues and gaps to prioritize issues and outcomes.
- Minimum three years’ experience in pediatric case management, experience in working with children with special health care needs preferred.
- Expertise in relationship building, community resource development, and person- and family- centered philosophy.
- Experience in coordinating community based services.
- Additionally, R.N. Care Coordinators will demonstrate high clinical competence, an ability to work in a team situation with other professionals and have the ability to carry out responsibilities with minimal supervision.
- Proof of current state licensure and current malpractice insurance coverage is required
- Cultural sensitivity and ability to communicate effectively with individuals with varied cognitive abilities to establish relationships.
- Ability to speak effectively with clients, partners and co-workers of the organization.
- Ability to read and interpret documents such as hospital discharge paperwork, assessment reports or medical records, and procedure manuals.
- Ability to learn new systems and experience with documenting in care management systems.
- Knowledge of working with private insurances regarding coverage is preferred.
In addition to the above qualifications, the successful incumbent is expected to:
- Maintain certifications and obtain appropriate professional development/CEUs as required by professional licensing, certification and accreditation boards.
- Support the mission and values of The Coordinating Center with a commitment to a person-centered, family-centered, culturally competent philosophy.
- Speak to groups of individuals with confidence and authority relative to the subject matter being presented.
- Commit to continuous quality improvement working with co-workers in a team oriented collaborative impact model.
- Adapt to the changing healthcare environment and legislation.