Care Coordinator CRMG

Summary

To develop and manage processes and pathways to ensure that CRMG practices are fulfilling the responsibilities of population health management within the practice setting.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

• Understanding and utilizing reports available to identify high risk patients.
• Assisting patients through the healthcare system by acting as a patient advocate and a navigator.
• Educates patients and caregivers on disease management and prevention.
• Monitors patient population on a daily basis to ensure population is compliant with medications, preventative visits, etc.
• Coordinates continuity of patient care with external healthcare organizations and facilities including hospitals and specialty care providers.
• Coordinates continuity of patient care with patients and families following hospital admissions, discharges and ER visits.
• Manages high risk patient care, including management of patients with multiple co-morbities or who are at high risk for readmission to a hospital setting.
• Communicates with providers on a daily basis steps that have been taken to ensure patient's health and safety.
• Collects and reports data that is pertinent to clinical audits and programmatic evaluation related to Patient Centered Medical Home and other population health initiatives.
• Develops and implements processes and pathways for population health management.
• Able to compile data from numerous resources to achieve total patient care.
• Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education : LPN

Preferred Education : BSN preferred

Experience : Program development and Patient Centered Medical Home experience preferred. Experience with electronic medical records and reporting required

Certificates, Licenses, Registrations

LPN or RN licensure in Virginia or North Carolina

CPR : BLS certification