Patient Centered Medical Home Care Coordinator - - Full-Time

Job Summary:
The PCMH Care Coordinator ensures the overall success of the Patient Centered Medical Home (PCMH) by collaboratively working with patients, physicians, practice teams, and the health plan to integrate the key features of the medical home, as defined. Engages the patient in an active role in the management of his/her disease or medical condition, and promotes education and self management skills. Assists in the identification of appropriate providers, facilities, and community resources in an effort to improve or maintain patients' social, emotional, functional, and physical health status. The focus of the Care Coordinator is to promote whole person health support with emphasis on establishing routine contact with the primary care provider and facilitate specialist referrals and other care as appropriate per physician orders. Additionally works to coordinate disease registry activities, performance reporting, and regular meetings with stakeholders regarding success or improvements within the medical home.

This position is involved in a team-based approach to care. Team members are trained to meet the highest level of function for their role as per the State of Tennessee/Georgia guidelines. Is trained and assigned (as per their role and responsibilities) to coordinate care for patients and is trained and assigned to support patients/families/caregivers in self-management, self-efficacy and behavior change. Is trained and assigned (as per their role and responsibilities) to manage the practices' patient population. Participates in the practice's quality improvement process and performance evaluation.

In addition, this position provides direct and indirect patient care under the direction of practice physicians, and works with resident physicians to promote an effective learning/training environment.

Education:
Required:
Licensed Practical Nurse
De-escalation training, if applicable

Preferred:

Experience:
Required:
Three to five years experience in direct patient care environment; must be PC literate with basic knowledge of Windows and Microsoft Office. Exceptional skills of independence, organization, communication, problem-solving, professional interactions, and human relation skills, as well as analytical skills and problem solving ability. Proficient with processes to build team and participate in cross-functional teams. Ability to work within specified timeframe requirements. Position requires Motivational Interviewing techniques and Adult Learning Styles. Excellent oral and written communication skills with problem solving abilities. Exceptional interpersonal communication skills are required. Experience with data collection, documentation review, and statistical analysis.

Preferred: 2 years' experience in Utilization Management, Case Management or Care/Disease Management. Extensive knowledge of Patient Centered Medical Home and NCQA certification.

Position Requirement(s): License/Certification/Registration
Required:
Licensed Practical Nurse with active license in the state of Tennessee or holds a license of their residence if the state is participating in the Nurse Licensure Compact Law.

Preferred:
N/A

The PCMH Care Coordinator contributes to Erlanger Health System through support of the philosophy and objectives.

Engages the patient in an active role in the management of his/her disease or medical condition, and promotes education and self management skills. Assists in the identification of appropriate providers, facilities, and community resources in an effort to improve or maintain patients� social, emotional, functional, and physical health status. The focus of the Care Coordinator is to promote whole person health support with emphasis on establishing routine contact with the primary care provider and facilitate specialist referrals and other care as appropriate per physician orders. Additionally works to coordinate disease registry activities, performance reporting, and regular meetings with stakeholders regarding success or improvements within the medical home.