Nurse Care Coordinator

NURSE CARE COORDINATOR

Details:

Hiring Company: Senscio Systems

Position Available: Full Time Immediate Need

Position Description:

Be part of a team that is changing how healthcare is delivered.

Senscio Systems is a Harvard, MA based company with current operations in MA, NH, ME, CT, RI, PA, NC and FL. Our passion is leveraging a unique, patented AI technology paired with a collaborate multi-disciplinary clinical team to support patients (we call them Members) with complex medical challenges. The Nurse Coordinator is responsible for facilitating, monitoring and follow-up on treatment plan requirements for patients enrolled in Ibis Health’s remote patient monitoring (RPM) and Virtual Care Coordination Programs. As a key member of the company’s interdisciplinary digital health team, the role ensures that Ibis Health members are informed, educated and coached on self-management, and in the use of the company’s tech-enabled care resources, reminders and notifications used to manage chronic conditions, avoid acute events, unnecessary emergency room visits and hospital admissions/readmissions.

Senscio’s future is bright. We have shown dramatic improvement in clinical outcomes and overwhelmingly positive patient experience scores, leading to tremendous projected growth in membership. If the idea of working independently while supported by a clinical platform and that helps ensure your quality impact is of interest to you, this opportunity may be for you.

Key Capabilities:

• Triage: Ability to understand, assess and correlate patient-recorded vital signs and symptoms to individualized patient treatment plan goals and evidence-based clinical guidelines.
• Communication: Understanding of chronic disease processes, and the ability to educate and coach Ibis Health members through the steps involved in self-management and adherence to established treatment plans.

Key Responsibilities:

• Care Coordination:
  • Assess patient needs, develop individualized care plans and coordinate services across healthcare providers.
  • Facilitate transitions of care, including hospital discharge planning and follow-up.
  • Act as a liaison between patients, families, providers and support services.
• Patient Advocacy & Education:
  • Educate patients and families on diagnosis, medications, treatment plans and self-care techniques.
  • Promote health literacy and empower patients to manage their care.
• Communication & Collaboration:
  • Work closely with physicians, APRNs, social workers, therapists, and other health professionals.
  • Attend care team meetings and ensure alignment on patient care goals.
• Documentation & Compliance:
  • Maintain accurate, up-to-date patient records in compliance with organizational standards and regulations.
  • Ensure care coordination activities meet applicable legal and ethical standards, including HIPAA.
• Quality Improvement:
  • Monitor and evaluate patient outcomes and adjust care plans as needed.
  • Participate in quality assurance initiatives and performance improvement projects.

Qualifications:

• Education: Associate or Bachelor of Science in Nursing (BSN highly preferred)
• Licensure & Certification:
  • Active Registered Nurse (RN) license in one of the following states: ME, MA, NH, RI, CT, PA, NC or FL, with an accompanying multi-state license or willingness to obtain one.
  • Case Management Certification (CCM or RN-BC) preferred.
• Experience:
  • Minimum of 2 years of clinical nursing experience (primary care, emergency and transitional care), chronic disease management, (i.e., diabetes, heart disease, pulmonary conditions, mental health, etc.)
  • Experience using electronic health records (EHRs) and care coordination/management applications.
• Skills:
  • Strong organizational, communication and critical thinking skills.
  • General knowledge of healthcare systems, insurance and community resources.
  • Ability to work independently and collaboratively in a fast-pace, virtual care environment.

Specifics:

• Competitive Salary.
• Benefit package including:
  • PTO.
  • Healthcare insurance stipend.
  • 401K.
  • Paid holidays.