RN Patient Care Coordinator

This position will assist in the management of patients with chronic diseases following established protocols and systems for disease management in collaboration with providers. Identifies patient populations requiring care management and resources necessary in the care of these patients. Possesses analytical skills to assess various patient utilization measures, such as ED, Urgent Care and Hospital Visits. Has the ability to monitor quality measures, looks for trends and makes plans for improvement.

Responsible to cover after-hours clinic on a rotating basis per clinic need

Education:

• Bachelor's Degree Nursing Preferred
  
  

License and Certifications:

• Active TN RN License Required
• BLS from American Heart Association Required
  
  

Experience:

• 2 years of experience Healthcare/Nursing Preferred
• Two (2) years of recent clinical experience as an RN working in a clinic/outpatient setting preferred. Understands and has the ability to apply principles of population management, disease management and utilization management to the care delivery process. Demonstrates knowledge of scope and role responsibilities for the roles of the RN, LPN, and MA. Must have the ability to assess, plan, implement, and evaluate the needs of the patient. The ability to communicate effectively in oral and written form, using good communication skills with a diverse population.
  
  

Job Duties: (Other duties as needed)

• Provide telephonic outreach and in-person consultation to members identified as high risk, having a chronic condition(s) and in need of preventive services.
• The PCMH Care Coordinator will collect in-depth health information about a member's health history as well as assess a member's individual needs to assist in identifying higher- risk members and develop a comprehensive plan of care addressing these particular needs.
• In collaboration with the physician, assess clinical information to develop a member-specific care plan. The PMCH Care Coordinator will involve the member as well as the member's care-givers in the determination of specific objectives, goals and action items identified in the assessment process. The plan of care will be oriented and time specific.
• Assist with coordination of care/services as well as care transitions working with both internal and external entities.
• Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provided.
• The PCMH Care Coordinator will facilitate and execute specific interventions to accomplish the established goals in the plan of care to ensure that the member's health, safety and welfare are at the forefront for each member.
• Collaborate with healthcare team to optimize patient adherence to medical plan of care, including: medication adherence, evidence-based care, and specific screenings for recommended preventive care.
• Utilize Nashville General Hospital Population Health Management tools, data and registry to improve quality outcomes, reduce unnecessary tests, document care plan, care notes and a psychosocial risk assessment on each member.
• Develop individualized goals with members to improve adherence and outcomes. 0 %
• Interacts with other departments to ensure the smooth transfer of member information across the continuum of care.
• The PCMH Care Coordinator will gather sufficient and relevant health information from all sources in order to determine the effectiveness of the plan of care, including regular prescribed contacts with the member and perform updates to the assessment and plan of care as needed.
• Proactively outreach to clients newly diagnosed with a targeted chronic condition;
• Perform medical chart reviews to confirm adherence to prescribed therapies (e.g. labs, medications); document findings in Nashville General Hospital electronic medical record and Population Health Management tool.
• Maintain requirements of documentation as reflected in audits to meet compliance with quality standards
• Participate in staff meetings as necessary.
• Ongoing education on The Clinics of Nashville General Hospital PCMH Quality Strategies as it relates to the PCMH clinical measures and established targets.
• Acknowledges patient's rights on confidentiality issues, maintains patient confidentiality at all times, and follows all HIPAA guidelines and regulations
  
  

Nashville General Hospital is an Equal Opportunity Employer/Disability/Veteran.