CRMG - Care Coordinator (Elizabeth City, NC)

Chesapeake Regional Healthcare•Elizabeth City, NC

3d•Onsite

About The Position

The Care Coordinator will provide annual wellness visits for identified patients, perform outreach to schedule these visits, and assess patients' health status. They will develop personalized care plans, conduct non-invasive assessments and screenings, review medical history, ensure accurate documentation, and perform medication reconciliation. The role involves educating patients on wellness and preventive healthcare, collaborating with primary care providers, and assisting patients in navigating the healthcare system. Additionally, the Care Coordinator will manage care for high-risk patients, coordinate continuity of care with external providers, and collect/report data for clinical audits and program evaluation. They will also develop and implement processes for population health management and compile data for total patient care. Flexibility in work scheduling may be required.

Requirements

Current LPN or RN licensure in Virginia or North Carolina
BLS certification
Primary care experience preferred
Demonstrated proficiency in assessing and managing patients with complex health conditions and multiple co-morbidities.
Prior Patient-Centered Medical Home experience preferred.
Experience with electronic medical records and data reporting required.

Nice To Haves

LPN or RN licensure in Virginia or North Carolina
Primary care experience
Patient-Centered Medical Home experience

Responsibilities

Provide annual wellness visits for identified patients.
Perform outreach to patients and schedule annual wellness visits.
Assess patients’ health status, identify risk factors, and develop personalized care plans.
Conduct non-invasive assessments and screenings, review medical history, ensure accurate documentation, and perform medication reconciliation.
Develop and update personalized prevention plans with patients.
Provide basic patient education on wellness and preventive healthcare measures.
Collaborate with primary care providers to identify health gaps and review findings from annual wellness visits.
Understand and utilize available reports to identify high-risk patients.
Assist patients in navigating the healthcare system by serving as a patient advocate.
Educate patients and caregivers on disease management and prevention.
Coordinate continuity of care with external healthcare organizations and specialty providers.
Coordinate patient and family follow-up care after hospital admissions, discharges, and emergency room visits.
Manage care for high-risk patients, including those with multiple comorbidities or at high risk for hospital readmission.
Collect and report data pertinent to clinical audits and program evaluation related to the Patient-Centered Medical Home and other population health initiatives.
Develop and implement processes and pathways for population health management.
Compile data from multiple sources to support total patient care.
Attend required hospital-wide orientations, meetings, and in-services.
Demonstrate flexibility in work scheduling when necessary to ensure patient care coverage.