Population Health Coordinator RN

Description

PURPOSE STATEMENT

Responsible for coordinating team-based care, to provide health services to individuals, through effective partnership with patients, their caregivers/families, community resources and members of the Care Team.

ESSENTIAL FUNCTIONS  

• Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
• Work with patients to plan and monitor care.
• Assess patient’s unmet health and social needs.
• Develop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).
• Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.
• Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time.
• Facilitate patient access to appropriate medical and specialty providers.
• Educate patient and family/caregiver(s) about relevant community resources.
• Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed.
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
• Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs) and add these to the patient registry (or flag in EHR).
• Attend all Care Coordinator training courses/webinars and meetings.
• Display knowledge of preventative health requirements.
• Display knowledge of patient centered medical home model concept.
• Maintain regular and predictable attendance.
• Perform other essential duties as assigned.

SHIFT REQUIREMENTS

• 2 days a week at Central Family & Sports Medicine and Family Practice of Central Missouri - Warrensburg clinics.

Requirements

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

• High school diploma or equivalent.
• Graduate of accredited school of professional nursing.
• Currently licensed to practice as a professional Registered Nurse (RN) in the state of Missouri.
• Current BLS required.
• Previous experience in caring for chronic disease patients preferred.
• Two years’ experience in clinical or community health setting preferred.
• Previous Care Coordination, Case Management or Home Health experience preferred.
• Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the hospital/clinic.

PHYSICAL/MENTAL REQUIREMENTS

• Must be able to sit and stand, intermittent 8 to 10 hours a day.
• Must be able to use standard office equipment, including the telephone and computer keyboard.
• Continuously works under pressure of near 100% accuracy while meeting inflexible deadlines.
• Continuously utilizes manual/bi-manual dexterity, near vision, speech, and hearing.
• Frequently stands, walks, sits and utilizes eye/hand coordination and color definition.
• Occasionally reaches above shoulder, occasionally required to life and/or carry up to 20 lbs.
• Occasionally walks on uneven surfaces.
• Ability to travel 0-10% of the time, including flying and driving rental cars.
• To accommodate travel, must be able to transport own suitcases and portable computer estimated at 20 pounds.