RN Care Coordinator

Department CMMC Primary Care Exempt
Immediate Clinic Nurse Manager (s) Non-exempt
Supervisor
Supervisor next Director of Clinic and Business Workweek
in line Development
POSITION SUMMARY
Coordinates Team-based care to provide health services to individuals, through effective partnerships with
patients, their caregivers/families, community resources and their physician. Facilitates a "shared goal model"
within and across settings to achieve coordinated high-quality care that is patient and family centered.
Continued employment and raises in this position are dependent upon Central Montana
Medical Center's fiscal viability and: 
Actions and communications that contribute to a team concept and create a
positive environment for all customers 
Acceptable performance of essential and all job duties 
Acceptable attendance record 
Accountability for safety to self, patients, visitors and all customers, and care of
equipment and building 
Adherence to departmental and facility policies and procedures, education
requirements, compliance monitoring and reporting, and CMMC Code of
Conduct 
Accountability for the consequences of own actions 
Physical and emotional ability to perform essential functions 
Acceptable background investigation results if required for position
Minimum Education, Experience, Licensure, Certification required:
Current RN license required;
Experience in care for chronic disease patients is required;
3-5 year’s experience in clinical or community health settings is preferred; and leadership, communication,
education, collaboration and counseling skills;
Previous Care Coordination, Case Management experience preferred;
Previous experience with mobilizing community resources, navigating patients through the healthcare
continuum and working with diverse populations preferred;
ESSENTIAL FUNCTIONS/DUTIES:
(Must be able to perform with or without accommodation)
1 Provides a coordinated, strategic approach to detect early and manage effectively the

chronically ill patient population.
2 Utilizes an effective internal tracking system for identified patients.
3 Coaches patients/families towards successful self-management of their chronic disease.
4 Will assess patient and family's unmet health and social needs. Position requires effective

communications to improve health literacy.
5 Help develop a care plan based on mutual goals with the patient, family and provider.
6 Monitor patient adherence to plan of care and progress toward goals in a timely fashion and

facilitate interventions and changes as needed.
7 Document all patient/caregiver interactions and provide progress updates to primary care

teams.
8 Facilitate patient access to appropriate medical and specialty providers both internally and

externally.
9 Cultivate and support primary care and subspecialty co-management with timely

communication inquiry, follow-up and integration of information into the care plan regarding
transitions-in-care and referrals.

10 Serve as the contact-point, advocate and informational resource for patient, family, care team,

payers, and community resources.
11 Ensure effective tracking of test results, medication management, and adherence to follow-up

appointments.
12 Facilitate and attend meetings between patient, families, care team, payers and community

resources as needed.
13 Attend and actively participate in all clinic related training and meeting activities.
14 Other duties as assigned.
Knowledge, Skills, Abilities:
Ability to communicate and effectively work with hospital personnel and medical staff
Ability to adapt to fluctuations in workload and work efficiently and effectively under stressful
conditions.
Willingness to assume additional duties when requested and seek guidance and direction, when
needed, for performance of duties and ability to recognize, establish and respond to priorities.
OCCUPATIONAL EXPOSURE for this position:

Category I Direct contact with blood or other bodily fluid to which
universal precautions apply

Category II Activity performed without blood/bodily fluids exposure,
but exposure may occur in emergency

Category III Task/activity does not ordinarily entail predictable
exposure to blood/bodily fluids

OTHER EXPOSURE for this position:
Radiation
Noise
Other (Specify)

PHYSICAL DEMANDS:
(Essential functions strength rating for position - see Job Analysis) Sedentary Exert up to 10# occasionally or negligible force frequently
Light Exert up to 20# occasionally, < 10# frequently or

negligible force constantly
Medium Exert up to 50# occasionally, up to 25# or up to 10#

constantly
Heavy Exert up to 100# occasionally, up to 50# frequently or up

to 20# constantly
Very Heavy Exert > 100# occasionally, > 50# frequently or

> 20# constantly