I. Primary Function -

The RN care coordinator will coordinate team-based care to provide health services and education to patients

and families through effective partnerships with Delaware Children Health Network (DCHN) practices,

community resources and medical professionals. Supports care coordination in the DCHN practice setting

by utilizing critical thinking skills and nursing expertise in order to optimize patient outcomes amongst

designated populations within the practice. Works with patients and families to ensure both medical and

psychosocial needs are met in order to promote health and well-being. Works with DCHN practices to

addresses gaps in care and promotes timely access to appropriate care, increasing the utilization of

preventative care and healthy behaviors to improve the health of the population at risk.

II. Essential Functions -

1) Assist with the identification of patients in the practice with special health care needs; by running

registry reports and use the registries to plan and monitor care. Monitors and audits patient

registries/lists in accordance with NCQA Standards. Assists children with special health care needs

and families in obtaining needed care to optimize quality of life and outcomes when possible.

Coordinate with insurances to help families understand their benefits.

2) Supports DCHN practices to initiate family contacts and facilitate patient access to, and

communication between, physicians and other team members.

3) Identify patient and family needs, gaps and/or barriers to care and patient/family strengths and

assets. Assess biopsychosocial needs of at-risk patients, i.e., single parents, substance abuse,

complex medical patients, behavioral health issues, etc. facilitating appropriate connection to

resources available to assist the patient and family to meet needs and overcome barriers to care.

4) Works cooperatively with families, patients, other members of the treatment team, social service

agencies, community resources, and public agencies. Collaborates with the family and team to

arrange for health care needs. Acts as a liaison for agencies and families with identified healthcare

needs.

5) Utilizes the nursing process to coordinate the care of an identified population of pediatric patients

throughout the healthcare continuum.

6) Supports DCHN practices in coordination of services such as, transportation, interpreter needs,

SDoH resources, referrals, and compliance. Assists families and patients through the healthcare

system by acting as patient advocate and navigator connecting patients to relevant community

agencies and resources with the goal of enhancing patient health and wellbeing.

7) Serve as point of contact for DCHN practices as an informational resource for family, patient, care

team, school systems and their school nurses, community resources, and state agencies.

8) Works with DCHN practices to re-educate patient/family about a condition (existing or newly

diagnosed) to assist them in appropriate self-management; referring to Care Management as needed.

Serves as the point of contact for Care Management to communicate with practice.

9) Participates on a team for data collection, health outcomes reporting, clinical audits, and program

evaluation related to the Quality Improvement metrics/measures as needed for

NCQA/Payor/Nemours. Assists with the identification of areas for improvement within their

practice. Reviews Navinet and assists with action around gaps and opportunities to meet risk

requirements.

10) Creates and promotes adherence to a care plan, developed in coordination with the complex

patient/family, care management team and primary care provider. Works closely with inpatient

Nurse Case Managers for discharge needs- hospital and NICU

11) Monitors specialty consults and follows up if patient/family did not follow through with the

appointment or the consult report was not received by the PCP. Helps connect families to specialty

appointments.

12) Works with DCHN practices with patient and family to facilitate access to the most appropriate care;

reducing emergency room utilization and unplanned hospital admissions/readmissions. Education

around hospital follow up in collaboration with Nemours Care Managers.

13) Educates DCHN practices regarding Care management and assists with care management referrals.

14) Coordination of Durable Medical Equipment needs and assists with Letters of Medical Necessity.

Completes Asthma Medication Ratio Reconciliation.

15) Works with DCHN practices to lead process/workflow change to improve compliance.

Bachelor's degree

BSN preferred

Current unrestricted DE nursing licensure required

More than 3 years relevant experience