RN Care Coordinator

Summary of Position

RN Care Coordinator will work with Cabarrus Rowan Community Health Centers, Inc. (CRCHC) patients and staff to provide proactive intervention and coordination of care to CRCHC patient who are receiving care in an inpatient community hospital or emergency department for physical health reasons to ensure that these individuals receive appropriate transitional care and services.

The RN Care Coordinator also works with identified high risk Medicaid Managed Care patients to create goals through care plans.

The RN Coordinator works with the patient and care team to identify and alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and / or coordination of services needed by the patient.

This collaboration with physicians and practice staff will drive improvement in clinical measurement outcomes and patient outcomes to promote the highest standards of quality for CRCHC patients.

Minimum Qualifications

Ability to communicate in English accurately and concisely both verbally and in writing. Interacts in a professional and patient-centered manner with patients.

Able to work cooperatively with internal staff to deliver safe, effective, quality care to all patients. Able to plan, prioritze and complete assigned tasks with a high level of accuracy.

Ability to work well under time constraints while maintaining accurate records

• Experience : 2 years of related work preferred, Care Coordination, Mental or Behavioral Health experience preferred.
• Additional skills preferred : CMS Stars, PCMH, and HEDIS clinical quality measures and healthcare metrics knowledge required.

Ability to understand and provide thoughtful input about strategic opportunities. EMR experience, Athena.

• Travel required- N / A
• Additional skills : Population health management database reporting experience. Managed Care experience.

Education : Registered Nurse

Certification(s) / Licensure : None

Physical Requirements :

The physical demands described here represent those that must be met by an employee to successfully perform the essential functions of this job.

• Continuous walking, standing and moving about.
• Frequently bends, kneels and crouches.
• Frequently lifts, pushes or otherwise moves and positions patients or other objects, exerting up to 50 lbs.
• Repetitive movement of hands and fingers - typing and / or writing.
• Talk and hear.

Key Responsibilities

1. Complete care coordination for all Medicaid Managed Care - high risk patients as identified through risk stratification to include a formal Care Plan in HealthEC and Athena.

2. Complete Transfer of Care for all Medicaid Managed Care patients as well as Medicare patients as assigned.

3. Interacts with patients, professionals, and the community to achieve continuity of care, coordination of services and to document plans of care across multiple care settings.

4. Conducts or participates in comprehensive "all-system" needs assessment for identified patients; knowledgeable of appropriate care-related services to match identified needs disease management for health maintenance, and appropriate clinical goal expectations / outcomes for identified population.

5. Develops and maintains accurate case records of each assigned patient.

6. Documents fully and accurately; knowledgeable of and utilize accurate computer databases and documentation systems.

7. Maintains knowledge of various reimbursement criteria and documentation necessary for reimbursement, including Medicaid, Medicare, and Managed Care.

8. Demonstrates leadership in the professional practice of nursing evaluating his or her own nursing practice in relation to professional practice standards and guidelines, relevant statues, rules and regulation

9. Support pay for performance plans as well as quality improvement projects and initiatives as assigned.

10. Work with clinical and administrative staff to develop creative processes to proactively manage high risk patient populations.

11. Identify underlying issues that may contribute to gaps in clinical quality performance; work with practice staff to close gaps and improve individual care team performance.

12. Through partnerships with patients, caregivers / families, community resources, and their care teams, coordinate appropriate interventions, cost effective delivery of quality care and services to achieve high-quality care that is patient centered.

13. Generate reports and monitor patient adherence to plan of care and progress toward goals in a timely fashion. Facilitate changes as needed.

14. Provides additional administrative support to all quality improvement department projects and initiatives.

15. Support current incentive, regulatory, and certification requirements (such as Meaningful Use, PCMH and UDS) through documentation, participation in initiatives, and other activities as directed.

16. Perform other duties as assigned.

CRCHC Core Requirements

• Patient Centered Customer Service - Whether directly or indirectly, we work to support the delivery of an excellent patient experience to everyone served by the organization.
• Caring and Compassion - We provide empathic comfort to those in distress and share kindness in all interpersonal interactions.
• Respectful Communication - We communicate openly, honestly and without judgment while honoring everyone's uniqueness and assuming the best of those with whom we interact.
• Teamwork - We are members of a diverse interdisciplinary team working together to meet a common goal.
• Accountability - We accept our individual and team responsibilities and we meet our commitments. We take responsibility for our performance and actions.
• Customer Safety - We recognize and correct potential hazards to protect ourselves and our customers.

CRCHC provides comprehensive, high-quality primary health care to our patients regardless of ability to pay. As a Federally Qualified Health Center (FQHC), we provide health care to all members of our community, including low income, indigent, and uninsured patients who may not otherwise be able to afford health care via traditional sources.

We screen potential employees to first ensure alignment with our core requirements followed by the requisite position skills set.

In doing so we need staff committed to this mission who do their best to live and work the characteristics of our core values as we strive to care for ever increasing members of the communities we serve.