Care Coordinator RN

The Clinical Coordinator works as part of the Patient Care Team to provide quality focused health care services driven by the SDHS mission and incorporating social determinants of health to eliminate barriers to care. Works closely with patients and the medical care team to provide organized, cost effective, patient-centered health services, while assisting to identify and facilitate closure of health care gaps across the continuum of care.

Duties:

• Serve as a liaison between patients and the healthcare system to ensure patients receive proper healthcare services without duplication through coordinating and organizing appropriate care.
• Identify high risk patients by closely working with the medical care team, insurance plans, and outside providers to include specialty offices, hospitals, and pharmacies.
• Identify and facilitate transition of care services to ensure timely follow up appointments, medication reconciliation, and access to resources needed to prevent readmission. Outreach to patients and families to provide instructions regarding medications and treatments.
• Review and address after-hours calls daily to ensure proper follow-up and health care needs are addressed.
• Provide patient advocacy by navigating to local resources including but not limited to Medicaid outreach, medication assistance, patient assistance funding foundations, in-home care opportunities, medical equipment, mental health services, and transportation considering social determinants of health.
• Supports patients through utilization of technology to accomplish health care communication and goals.
• Works closely with the Director of Quality Improvement and CCO in direct collaboration with insurance payers to facilitate care and satisfy identified heath care gaps. Works as a team to improve UDS and HEDIS quality measures.
• Perform chart documentation updates to satisfy requirements for quality measures, health reminders, medical history, problem lists, medication reconciliation and immunizations. Assists to review and update 340B chart documentation requirements.
• Oversees patient identification, facilitates notification/scheduling, and performance of Annual Medicare Wellness Visits in collaboration with clinical staff. Identifies and facilitates scheduling of Preventative Care visits for all age groups to address evidence-based screening recommendations, immunizations, and care goals.
• Develops care plans correlating to the management of chronic care conditions and document within the care plan module of the EHR to satisfy PCMH requirements.
• Identify patients with uncontrolled chronic care conditions, including Diabetes and HTN, and work directly with the patient’s care team to individualize coaching, counseling, and pathways to optimize care goals. Coordinates diabetic education for identified patients of need.

Requirements:

• Must be licensed with Virginia State Board of Nursing with a current RN license.
• Clinical experience, patient education, assessment, and critical thinking skills necessary to perform the duties of this position. 5 years of nursing experience preferred.
• Strong verbal, written, reporting and clinical documentation skills assuring accuracy and compliance with regulatory standards.
• Personal and professional qualities permitting the Clinical Coordinator to work with staff and patients of the health center in such a manner as to earn their confidence and respect while observing effective communication and customer service skills. Must exude cultural sensitivity and demonstrate empathy with all patient interactions and needs.

SDHS offers a competitive salary and benefit package. No nights, weekends, or on call required for this position. This position offers the opportunity to make a meaningful impact on patient care while working within a collaborative healthcare environment. Join us in providing high-quality care coordination services to enhance patient outcomes.

Resume can be submitted via really, or faxed to (434) 696-2149.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Experience:

• Case management: 1 year (Preferred)
• Nursing: 1 year (Required)

License/Certification:

• RN (Required)

Ability to Commute:

• Emporia, VA 23847 (Required)

Willingness to travel:

• 25% (Preferred)

Work Location: In person