RN Care Coach

The RN Care Coach is an integral part of the ilumed clinical team, providing a comprehensive, patient-centered approach to Chronic Disease Management programs. This role focuses on coordinating patient care and ensuring efficient resource utilization for beneficiaries by assessing, planning, implementing, coordinating, monitoring, and evaluating available care options. The ultimate goal is to empower beneficiaries to achieve optimal health outcomes, enhance their quality of medical care, and drive improved clinical outcomes. Through comprehensive assessment, strategic care planning, proactive coordination, continuous monitoring, and evidence-based evaluation, the RN Care Coach works to reduce barriers to care, educate on disease management awareness, enhance the quality of medical outcomes, and improve key performance indicators related to patient engagement, intervention effectiveness, and enhance overall quality performance metrics within the organization. The RN Care Coach is responsible for monitoring patient progress, ensuring the effective implementation and execution of care plans, and leveraging data-driven insights to refine intervention strategies. Through ongoing assessment, evaluation of trends in care effectiveness, and proactive problem-solving, this role plays a critical part in enhancing care delivery, optimizing healthcare resource allocation, and decreasing preventable hospital readmissions.

Provide telephonic care guidance and support to beneficiaries, families, and caregivers, ensuring proper education, care coordination, and support per the established plan of care. Collaborate within Care Management programs, working with physicians and providers to develop fully integrated care plans that address beneficiary needs. Utilize Motivational Interviewing and solution-focused communication to effectively engage beneficiaries. Meet departmental KPIs for calls per day and caseload, ensuring efficiency and effectiveness in care management. Demonstrate strong critical thinking in decision-making and problem-solving processes. Adapt to patient-centric needs, tailoring care strategies to individual beneficiary circumstances. Time management proficiency, balancing multiple priorities to meet performance goals. Identify Social Determinants of Health (SDOH) needs and connect beneficiaries with community resources for essential services. Maintain privacy, confidentiality, safety, and advocacy, ensuring adherence to ethical, legal, and accreditation/regulatory standards. Participate in professional development activities, staying current on industry best practices, case management procedures, and licensure requirements. Perform all duties within the scope of licensure. Performs additional duties as assigned. Travel on company business as requested.