RN Care Coordinator PCMH - Strategic Insurance Development

Guthrie Enterprise•Owego, NY

13d

About The Position

The RN Care Coordinator in Primary Care serves as a practice support for Patient Centered Medical Home (PCMH) development and processes. This role is an integral part of the PCMH Team, responsible for coordinating the medical management of patients using an outcomes-based approach. In collaboration with the healthcare team, the Care Coordinator identifies at-risk patients, develops care plans, and coordinates care with patient involvement. The position supports the PCMH initiative by working with physicians and other providers to meet quality process and performance objectives through data collection, analysis, and outcome evaluation.

Requirements

Licensed Registered Nurse.
Bachelor’s Degree in Nursing or related field required.
Must be licensed in both New York and Pennsylvania.
Must have a current license as a Professional Registered Nurse in their state of practice prior to position start date.
Additional state licensure must be obtained within 6 months of hire.
A minimum of five (5) years of relevant clinical experience (as an LPN or RN) who demonstrate leadership and autonomy in nursing practice.
Demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures.

Nice To Haves

Master’s Degree preferred.
Consider applicant who is actively pursuing their bachelor’s degree with an employment agreement.
Preferred experience with PCMH process, care management/utilization review, and payer knowledge.
Fast paced ambulatory care experience preferred.

Responsibilities

Actively manages a panel of high-risk patients using motivational interviewing, shared decision making, and goal setting to increase patient/family engagement.
Uses technology, such as tele-visits and remote monitoring capabilities, to engage patients and monitor chronic health conditions.
Measures improvements in process and quality of care through evidence-based guidelines.
Provide Transitional Care Management (TCM) following an inpatient stay for all identified patients.
Collaborates with patient, physician, and other care team members in assessing the patients progress toward individual health care goals.
Provides follow-up information for the patients indicated to ensure compliance with recommendations, medication, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc.
Supports the PCMH initiative at the practice level through involvement with quality improvement initiatives, participating in PCMH/Population Health meetings, and educating on best practice models as needed.
Supports the primary care practice with the use of technology, including Microsoft and EPIC Software. Functionality would include reporting Workbench, Patient Outreach (eGuthrie, Health Maintenance, Care Everywhere, EPIC Care Link) and Disease registry tools.
Is an active member of the Care Coordination team through participation on regular team meetings and regional Case Management meetings, as well as leading discussions and teachings to practice level staff on chronic disease management and high-risk patient management.