RN Care Coordinator, Neurology

Job Description

To facilitate and manage care coordination and case management across the continuum of care for UC Health patients. Working within a collaborative framework, insures the effective and efficient coordination and management of care to all patients within his/her caseload. This individual works to ensure that patients move along the health care continuum, promoting quality care, through appropriate, cost- effective interventions while maintaining close contact with patients, families, care providers, payers and community resources.


  • Engages in population appropriate communication.
  • Has knowledge of growth and development milestones and tasks.
  • Gives clear instructions to patients/family regarding treatment.
  • Involves family/guardian in the assessment, initial treatment and continuing care of the patient.
  • Identifies any physical limitations of the patient and deploys intervention when necessary.
  • Recognizes and responds appropriately to patients/families with behavioral health problems.
  • Interprets population related data and plans care appropriately.
  • Identifies and responds appropriately to different needs resulting from, unique psychological needs or those associated with religious / cultural norms.
  • Performs treatments, administers medication or operates equipment safely. Recognizes and responds to signs/symptoms of abuse or neglect.

Patient Services Staff
  • Sustain an understanding of regulatory requirements and accreditation standards.
  • Supports leadership in Compliance efforts to meet and sustain the regulatory compliance efforts of the department and hospital.
  • Monitor safety and departmental policies and procedures.
  • Ensure all employee certifications and UCH training along with yearly training requirements are fulfilled in a timely basis.
  • Work with department managers, nurses and nursing leadership and multidisciplinary representatives to identify and share safety best practices.
  • Comply with all of UC Health ' s processes and freely communicate safety and compliance concerns to leadership.

Interprofessional Practice:
  • Demonstrate consistent integration of the Interprofessional Practice Model (IPM) in all aspects of practice.

Patient Care:
  • Possess knowledge of Age Specific and Culturally Diverse human growth and development Consistently integrate age specific and culturally diverse concepts into patient care, taking into consideration both the patients ' chronological age and developmental functioning.

  • Conduct a comprehensive assessment of health and psychosocial (Social Determinants of Health) needs.
  • Identify cases that meet criteria for case management (Comprehensive needs assessment).
  • Meet each new patient within the caseload to introduce self and explains the Case Manager Role. Identify the patient ' s support system and financial situation and initiate referral to Social Work as needed.

  • Plan with the client, family or caregiver and the provider to document a patient centered plan of care focused on achieving quality, and cost effective outcomes.
  • Work with the patient/family, establish self-management goals that meet the patients ' healthcare and safety needs.
  • Integrate patient/family decisions and choice into the planning process.
  • Coordinate the plans of care and maintain documentation of case updates and discussion/events involving individuals responsible for patient welfare (e.g. family, providers, and care team members).
  • Identify the need for patient/family team meeting, participate in the meeting and documents the outcomes.
  • Proactively identify opportunities for coordination and efficient care and advocates on the behalf of the patient to achieve the best outcome possible.
  • In collaboration with the provider (s) reassess plan of care and adjusts plan according to patient needs.

  • Assume accountability for facilitating patient ' s plan of care.
  • Provide self-management support for high risk/complex patients and families.
  • Utilize collaborative communication skills to establish a working partnership with the patient/family, treatment team, and community resources/providers.
  • Educate the client, the family or caregivers and members of the health care delivery team about treatment options.
  • Empower the client to problem-solve by exploring options of care when available and alternative plans, when necessary, to achieve desired outcomes.
  • Encourage the appropriate use of health care services and strives to improve quality of care and maintain cost effectiveness on a case by case basis.
  • Support and facilitate all care transitions from inpatient to outpatient, practice to practice and from pediatric to adult systems of care.

  • Facilitate communication and coordination between members of the health care team (including the medical home and community services), involving the client in the decision-making process in order to minimize fragmentation in the services.
  • Attend and participate in daily rounds, setting priorities and adhering to time frames (inpatient).
  • Insure the key components of the plan of care and/or patient needs are communicated to subsequent care providers, both ambulatory and inpatient.
  • Document summary health information for handoff communication ensuring safe transitions of care.
  • Negotiate and advocate for the patient for services and resources needed.
  • Provides patient/family education regarding post-acute services, community resources or other as needs identified.
  • Create an environment to support patient safety by integrating patient safety goals into daily practice based of the patient ' s age and populations served.
  • Demonstrate an understanding of legal and regulatory issues (HIPPA, EMTALA, regulatory agencies, UC, legal P&P) impacting the care delivery and reimbursement process.

  • Monitor the patient ' s progress in achieving the goals, objectives, and expected outcomes of the plan at specified time frames.
  • Monitor patient and health care providers to ensure quality and completion of services.
  • Utilize Critical Pathways and /or Clinical Guidelines to monitor patient progress toward health.
  • Follow through on the status of key diagnostic and treatment tests/procedures to insure continued progression.
  • Interact with involved departments to negotiate and expedite scheduling and completion of tests and procedures.
  • Identify, documents and communicates barriers to the plan of care to the healthcare team.

  • Evaluate the timeliness and availability of treatments and services, and adjusts level of services according to changing needs.
  • Evaluate actual patient outcomes in relation to expected outcomes, Identify improvement opportunities and communicates them to unit ' s management team, providing supporting data when possible.
  • Participate in the management of metrics (outcomes, value, and experience) across the continuum of care.

  • Lead by understanding population and individual level outcomes, advocating for continuous improvement in quality, safety and efficiency.
  • Lead in the development of processes and systems to measure/monitor practice.
  • Participate in productivity monitoring and peer auditing to maintain quality case management.
  • Guide healthcare team in delivery of appropriate nursing practice to achieve improved patient outcomes.
  • Collaborate with care team, interdisciplinary departments at the system level to plan, implement, and/or evaluate services.
  • Serve as a resource for other members of the health care team. Participate in departmental education.
  • Identify own practices abilities and limitations and obtains instruction and supervision as necessary.
  • This includes seeking education for self-development.
  • Demonstrate adherence to the Code of Ethics of profession and according to system policy.
  • Demonstrate ability to hold self and other providers accountable.
  • Practice supports departmental/hospital policies, procedures and standards.
  • Monitor emails, phone messages and responds in a timely manner.


  • Bachelors Degree - Minimum Required - BSN or a Bachelor Degree in Medical Technology, Microbiology, Public Health, Epidemiology, or other relevant field.
  • Current Ohio license as Registered Nurse or Current Licensure in Medical Technology, Microbiology, Public Health, Epidemiology, or other relevant fields.
  • Maintenance of professional credentials.
  • Acquisition and subsequent maintenance certification in infection control (CIC) within 3 years of hire

  • 2-3 Years equivalent experience - Preferred