RN CARE COORDINATOR

Position Summary

The Care Coordinator Nurse (RN) serves as an essential addition to the Medical Home Care Team by coordinating the care of patients, navigating patients through systems to improve health, and providing clinical supervision to assigned clinical team members.

Key Responsibilities

1. Participate as a valued member of the PCMH Care Team to oversee the coordination of patients and PCMH as a whole.
2. Use stratification tool to identify patients appropriate for care coordination.
3. Prepare handoff tool that identifies patient gaps that need to be closed.
4. Review medical records to ensure completeness prior to patient exam, obtaining missing documentation, lab reports, and consultation results. Documents clinic visits, observations, and related activities. Prepares and maintains required reports, records and files.
5. Coordinate the scheduling and referral of patients for specific treatments, procedures, home health services, and hospital admissions.
6. Track referral reports
7. Conduct holistic assessments during patient visits to assess the needs and goals of patients and also alert other care team members about patient needs.
8. Develop and maintain individualized and proactive care plans for care coordination population.
9. Works with care team to focus on disease-specific self-management and medication adherence, while providing support, information and education for specific diseases.
10. Provide communication and support to the providers on all assigned cases.
11. Navigate patients through systems and across transitions.
12. Contact patients appearing on registries and in need of treatment and/or follow-up
13. Document data and interactions with patients in electronic medical records
14. Instruct individuals, families, or other members of the patient’s care team on health education, disease prevention, or community resources.
15. Collaborate with other care team members to proactively perform care coordination for patients that are enrolled in care coordination.
16. Communicate patient concerns that need to be addressed during Huddle with Team Nurse
17. Assist with the completion of tasks assigned to the care team from the EHR such as prescription refills or communication of lab results.
18. Provides patient education
19. Responds to patient telephone calls
20. Assist care management patients with achieving set goals by implementing relevant nursing interventions
21. Assists patients in care coordination with scheduling appointments with specialists.
22. Conducts clinical follow-up calls
23. Monitors the quality of patient care.
24. Provides back up to support patient care functions
25. Oversees the completion of annual competencies of assigned staff
26. Performs other clinical duties as needed

Requirements

Experience: Two years of health-related care supervisory experience is preferred, but not required

Licenses or Certifications: Active RN licensure and valid BLS Certification