Job ID: 289793090
Last Updated: 2/10/2021
RN Care Coordinator
COMMUNITY HEALTH CENTERS OF GREATER DAYT
The Care Coordinator works in collaboration and ongoing partnership with chronically ill or high risk patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and other community resources in a team approach.to:
Promote timely access to appropriate care
Increase utilization of preventive care
Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider and family/caregiver(s)
Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care and referrals
Increase patients ability for self-management and shared decision-making
Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs
Increase comprehension through culturally and linguistically appropriate education
Reduce emergency room utilization and hospital readmissions
Enhances cost effectiveness by addressing care gaps and avoiding service duplication
Principal Duties and Responsibilities
Serve as the contact point, advocate and informational resource for patients, care team, family/caregiver(s), payers and community resources.
Work with patients to plan and monitor care:
a) Assess patients unmet health and social needs
b) Develop a care plan, with patient, family/caregiver(s) and providers
c) Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner and facilitate needed changes
d) Create ongoing process for patients and family/caregiver(s) to determine and request care coordination support they need or desire
e) Evaluate outcomes of care
Facilitate patient access to appropriate medical and specialty providers
Educate patient and family/caregiver(s) about relevant community resources
Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up and integration of information into the care plan regarding transitions-in-care and referrals
Assist with the identification of high risk patients and ensure that alerts are in the EHR
Appropriately, and routinely, document activities in the patients EHR
Attend Care Coordination training courses, webinars, etc to remain current on regulations, practices, etc
Provide feedback to, and participate in the Quality Assurance Program
Provide medication reconciliation.
Develop and maintain data system to track patient outcomes.
Maximize reimbursement through the management of quality based payment programs, to include: identifying gaps in care and implementing methods to close gaps in order to obtain quality/outcome based payments and bonuses.
Perform other duties as assigned
Required Skills or Abilities
1. Ability to manage and prioritize multiple tasks.
2. Excellent working knowledge of EHR, Next Gen preferred
3. Proficient in Excel, Word and PowerPoint and ability to learn other computer programs.
4. Good organizational and self-management skills
5. Excellent verbal and written communications skills
6. Ability to communicate with a diverse range of people, from physicians to the patient population.
7. Demonstrates knowledge of, and adherence to patients rights, confidentiality and HIPAA guidelines and regulations
8. Knowledge of local community health and social welfare resources preferred
9. Ability to relate well to people from diverse ethnic and cultural backgrounds
10. Demonstrates strong working knowledge of PCMH processes and guidelines
Required Knowledge, Experience or Licensure/Registration
1. Registered Nurse with current, unrestricted license in the state of Ohio
Maintain current certification with CEU requirements.
2. Previous experience in clinical or community resource setting required. Care coordination and/or case management experience preferred.
3. Current CPR certification.
4. Knowledge of ICD-10 and CPT coding preferred
Must be able to see, sit, stand, bend, stoop, hear and lift up to 20 pounds. Must demonstrate
manual dexterity in order to follow necessary clinical procedures.
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