Clinic Care Coordinator

Crook County Medical Services District

1d•Hybrid

About The Position

The Primary Care Coordinator is a full-time nursing position responsible for coordinating health services to patients to keep them healthy through wellness and prevention. This position will serve to support the CCMSD Primary Care Coordination programs as the programs continue to grow. At CCMSD we are uniting industry-leading solutions to build an integrated care model that addresses an individual's physical, mental, and social needs. Our goal is to help patients navigate and connect care to create a seamless health journey for patients across care settings. The Care Coordinator position will be a hybrid work schedule and will report to the CCMSD clinics with some remote work available. This position will support the development of care plans, appointment scheduling, referral processing/follow-up, medication management, phone triage, and patient/family/facility communication and will be expected to travel as needed. The Care Coordinator will engage patients and their families for disease management and education sessions to encourage positive behavioral modifications appropriate for the patient.

Requirements

High school diploma or equivalent required. Associates or Bachelors preferred.
Must be a Licensed LPN/LVN or Registered Nurse.
A minimum of two (2) years care coordination or hospital experience, including post-discharge transitions of care preferred, but not required.
1-3 years relevant experience in patient navigation preferred. Population specific experience is very important.
Experience with Medicare and Medicaid Payers.
Knowledge and experience with electronic medical record (EMR) and Care Management technology
Display a strong customer service, patient-focused orientation.
Ability to be flexible in an ambiguous, dynamic, and growing environment.
Strong collaboration and conflict resolution skill sets
Strong decision making and problem-solving skills.
Effectively engages diverse populations and provides culturally sensitive coaching, education, and assistance.
Ability to develop, prioritize and accomplish goals/time management.
To work remotely, you must have a strong internet connection, quiet space to take calls and a professional (distraction free) environment in which you can remain HIPPA compliant.
Some expectations of travel depend on patient and facility needs.

Responsibilities

Detailed review of EMR record to inform initial outreach and care plan areas of focus.
Perform comprehensive assessments for both physical and psychosocial risk factors that support individual patient needs while identifying and addressing barriers.
Communicate assessment findings, care plan goals, interventions and outcomes to provider, patients, and caregivers in a timely manner.
Monitor patient's ED visits and acute stays, perform post-discharge follow up calls and continuously assess risk of readmissions post-discharge.
Utilize motivational interviewing to promote patient engagement and empower patients to develop self-management skills.
Provide chronic disease education and symptom management teaching to patients and caregivers.
Communicate proactively with provider to address patient change in status or obtain any necessary referrals/orders.
Document care plans, clinical interventions, and outreach in care management software system.
Develop and maintain effective professional working relationships with assigned providers andother care management team members.
Travel to patient's homes or facilities if needed.
Connect the patient to community resources or assist in problem solving due to a lack of patient resources.
Accepting transfers from the Patient Enrollment team to conduct preliminary health assessments for newly enrolled patients in our network.
Resolve patients' questions and create an open dialogue to understand needs.
Assist with medication management, including identifying potential medication concerns, adherence, and coordinating refills.
Assist in ensuring timely delivery of services to your patients; Home Health, DME, Home Infusion, and other critical needs.
This individual must be able to quickly adapt to a fast-paced work environment. This role requires most of your shift on the phone.