JOB REQUIREMENTS: Pillar Health is looking for experienced Registered Nurse Care Coordinators. $5,000 hiring bonus - See below for details. POSITION SUMMARY The Registered Nurse Care Coordinator (RNCC) has a vital role within the KCHC/Pillar Health integrated care model. As a key partner to an assigned care provider(s) they support management of a patient panel using proactive and planned care goals while also coordinating the care team necessary to achieve them. The RNCC participates in the delivery of evidence-based care to an assigned patient population utilizing defined care standards, identifying care gaps, ensuring efficient access to care, care planning, and facilitating seamless care transitions and care continuity. The RNCC also participates in the analysis of outcomes, identification of opportunities for improvement, and implementation of changes to optimize outcomes for individual patients and the overall population. The position of the RNCC in the care model places the role in a unique position to facilitate an inter-professional team of clinicians in a wraparound care coordination model that will identify and address patient emergent, chronic, preventative care and social needs placing place patients in the best position for optimal health outcomes. ESSENTIAL FUNCTIONS The list of duties and responsibilities is not all inclusive and may be expanded to include other duties and responsibilities, as management may deem necessary from time to time. Coordination and Management of the Patient Panel * Reviews and assesses patient registration data, including outpatient or inpatient treatments, emergency room visits, medications, chart reviews, to assist in the monitoring and facilitation of adherence to prescribed care plans. * Using the Electronic Health Record (EHR) and other electronic resources to identify patient care gaps and coordinate activities with the provider and care team to close those gaps. * Utilizes organization defined risk stratification tools, EHR, and other electronic resources to risk stratify the assigned patient panel and track indicators of the panel. * Chronic Care Management of medium, rising risk and high-risk patients * Draw conclusions from available data to develop an overall strategy for the assigned patient panel as a whole, and individual patients in the different risk groups. * Routinely evaluates social needs that can negatively impact health outcomes. Connects patients to available resources to meet those needs. * Initiates or contributes to the development and implementation of individualized, comprehensive care plans including medical and social needs. * Accesses internal and external resources to support development and implementation of... For full info follow application link. Kenosha Community Health Center is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability or veteran status. ***** APPLICATION INSTRUCTIONS: Apply Online: ipc.us/t/A4BAAF874E0546D5