Continuing Care Coordinator RN

As our Continuing Care Coordination RN for Population Health at Dignity Health, you will be a vital part of a team dedicated to improving patient outcomes beyond the hospital stay. You will actively manage a panel of patients, focusing on those with complex needs, chronic conditions, and frequent hospital admissions.

Your primary role will be to coordinate care transitions, ensuring a smooth and safe journey for patients from the hospital back to their home or another care setting. You will develop and implement personalized care plans, educate patients on self-management, and connect them with community resources to prevent readmissions and improve their overall quality of life.

You will collaborate closely with an interdisciplinary team, including physicians, social workers, and pharmacists. Using a data-driven approach, you'll identify gaps in care and work proactively to address them, ultimately driving better health outcomes for our patient population.

• Develops a plan of care based on a nursing assessment of the patient and their individual circumstances.
• Participates in development of workflows and audits
• Coordinating care across multiple provider sites and interdisciplinary teams
• Leads an interdisciplinary healthcare team in the management of high risk patients referred to the Continuing Care program
• Assists patients and or caregiver with navigating the healthcare system to minimize fragmentation in services, obtain timely care and appropriate access to providers, services and necessary procedures anticipating barriers to care when possible.

Required
● Graduate of an accredited school of nursing.
● Minimum two (2) years of acute hospital clinical experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.

● AZ RN license

Preferred
● Bachelor's Degree in Nursing (BSN) 
●3 to 5 years of nursing experience.

Dignity Health Medical Group is the employed physician group of Dignity Health Arizona. Dignity Health Medical Group (DHMG) employs approximately 200 providers and 500 support staff that cover a wide variety of specialties. The medical group has had tremendous success over the past few years and now provides more than 73 subspecialty services. The physicians provide clinical services in their areas of specialty and many serve in pivotal academic, research and leadership roles. DHMG is also heavily involved in preparing tomorrow's healthcare providers. DHMG has 84 medical school students and approximately 200 residents and fellows throughout the 25 academic programs. Clinical services are complemented with translational and bench research to augment medical education for residents and students. The mission of Dignity Health Medical Group is consistent with Dignity Health's mission and St. Joseph's guiding principles with a focus on innovative clinical care and the pursuit of excellence through scholarly activities. As part of the Dignity Health hospital system, DHMG has full access to the staff and all facilities on our hospital campuses. This unique relationship with our hospital allows Dignity Health Medical Group to provide its patients with state-of-the-art patient services including care of the poor and disenfranchised. Look for us on Facebook and follow us on Twitter. For the health of our community ... we are proud to announce that we are a tobacco-free campus