Care Coordinator - Medical Group

Job Description

Job Description

The primary role of a Registered Nurse (RN) or LPN (Licensed Practical Nurse) Care Coordinator is to provide high quality, holistic healthcare to patients with multiple chronic and preventive conditions (high risk patients) through a patient-centered approach to improve their lives. Primary responsibility of Remote Monitoring and Chronic Care Management

ESSENTIAL JOB FUNCTIONS :

• Supports and empowers patients throughout health care continuum to include holistic counseling, problem solving “barriers to care” issues and coaching clients as needed re : treatment and medication adherence, healthy life choices, and self-help behaviors.
• Responsible for providing appropriate care and follow up to high-risk patients.
• Use monthly reports to monitor patient outcomes, review results with providers, and take appropriate follow up action with patients.
• Performs nursing assessment / medical triage of acute medical issues and medication side effects and refers or monitors appropriately.
• Provides chronic disease and preventive screening education to clients / families / partners, internal staff and external agencies in an organized and appropriate manner.
• Works to assist clients in accessing support services by serving as a liaison with other community agencies and connect patients with financial assistance and entitlement resources as needed.
• Manages patient referrals and follow-up to other specialty medical, mental health, substance abuse and community services.
• Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulations, and correspondence; ability to write routine reports and correspondence; and ability to present information in one-on-one, small group, and large group situations to management and staff.
• Consults with physicians, health care providers and outside agencies regarding continued care / treatment.
• Use the Electronic Medical Record system according to established guidelines.
• Work as an interdisciplinary team member with Medical Group at MHP.
• Participates in training and education to foster continued professional growth and assure high quality care delivery.
• Provides assistance with direct nursing interventions such as venipuncture, wound care, vaccinations and other identified nursing responsibilities.
• Ensures billable procedures are correctly documented and submitted in a timely manner.
• Ability to work with mathematical nursing concepts.
• Ability to operate related computer applications (i.e. word processing and spreadsheet applications), and business equipment including personal computer, copy machine, fax machine, and telephone.
• Well organized with the ability to maintain attention to detail. Good conceptual, organizational, and problem-solving skills.
• Conduct self in accordance with Mahaska Health Partnership's confidentiality policy; ensuring to follow all MHP training guidelines in accordance with the Health Insurance Portability and Accountability Act of 1996.
• Maintain a cooperative working relationship with employees, visitors, medical staff, and patients, keeping in mind the person’s unique needs within their age category (refer to Mahaska Health’s Age Specific Standards of Care Policy).
• Ability to deal with confidential information.
• Must be able to perform the physical demands of the job.
• Maintains regular and reliable attendance. Attend meetings, as requested.
• All other duties as assigned or requested.

JOB REQUIREMENTS :