RN Care Coordinator

Robert C. Byrd Clinic•Lewisburg, WV

10d•Onsite

About The Position

WVSOM Health is expanding its care coordination team and seeking a full-time Care Coordinator. This role supports physicians, mid-level providers, and nurses in delivering patient care within a clinic environment. The Care Coordinator will assist patients who call the clinic and serve as an essential member of the interdisciplinary care team, delivering high-quality care to patients both in-person and through telephone and EHR portal communications in a timely manner. This position will also be responsible for assisting with Chronic Care Management (CCM), Transitional Care Management (TCM), and Remote Patient Monitoring (RPM).

Requirements

Graduate of an accredited RN program or an accredited School of Practical Nursing
Strong communication and customer service skills are essential for success.
Thorough knowledge of disease processes to ensure appropriate triage and care for patients.
Comprehensive understanding of healthcare practices and protocols.
Excellent computer skills, preferably with experience using electronic health record (EHR) platforms.
WV licensure as a Registered Nurse or Practical Nurse
Current BLS Certification.
A minimum of three years’ experience in a clinical setting.

Nice To Haves

Knowledge of CMS guidelines and documentation requirements for Chronic Care Management, Transitional Care Management, and Remote Patient Monitoring preferred.
Experience with care coordination, chronic disease management, population health, or value-based care preferred.

Responsibilities

Provide direct care to patients as assigned and qualified to perform while under the direction of a nurse, physician orders, or established protocols.
Answer phones courteously, assisting patients with healthcare inquiries, and handling upset patients with de-escalation techniques.
Document all phone interactions, including attempted calls, in patient charts.
Conduct phone interviews to gather necessary information for providers.
Schedule patient appointments promptly and return calls by the end of the day.
Welcome patients warmly, addressing concerns and easing anxiety.
Triage patients based on care urgency and clinic protocols.
Record vital signs accurately and update patient histories.
Conduct initial patient assessments and participate in patient education.
Maintain accurate patient records and complete charting promptly.
Process stat referrals efficiently.
Assist with patients enrolled in Chronic Care Management (CCM) programs, including monthly patient outreach, care plan development and updates, medication reconciliation, goal setting, and documentation in accordance with program requirements.
Assist in performing Transitional Care Management (TCM) activities, including timely post-discharge patient outreach, medication reconciliation, coordination of follow-up appointments, patient education, and communication with providers and community resources.
Assist with monitoring and managing patients enrolled in Remote Patient Monitoring (RPM) programs by reviewing transmitted physiologic data, identifying abnormal findings, notifying providers of significant changes, providing patient education, and documenting interventions.
Coordinate care among primary care providers, specialists, hospitals, home health agencies, pharmacies, and community resources to promote continuity of care and reduce hospital readmissions.
Maintain accurate and timely documentation to support CCM, TCM, and RPM services, ensuring compliance with CMS, payer, and organizational requirements.
Participate in quality assurance and patient care meetings.
Other duties as assigned.
Adhere to WVSOM Health's high standards of customer service excellence.