Care Coordinator

Job Summary:
  • The function of a Care Coordinator is to manage the care of the patient outcomes, assist patient to use healthcare resources appropriately, and work with patients to set goals for better health. Care Coordinators also assist the providers to close preventative care gap needs, find documentation and resources to care for patient.
Job duties and responsibilities include, but are not limited to:
  • Follow up on all Inpatient hospitalized patients including but not limited to current status, medication reconciliation, any home needs for safe care, teaching for safe rehabilitation, scheduling a follow up with PCP or specialists as indicated.
  • Follow up on all Emergency Room visits by patients for current status, medication changes in ER, home needs for recovery, social barriers that led to ER visit, needs to avoid further ER use, and follow up with PCP or specialists as indicated.
  • Promote and reinforce preventative health maintenance for all patients.
  • Develop and utilize Care Plans when appropriate for high risk patients.
  • Risk Score patients when applicable.
  • Make regular follow up for patients deemed Chronic Care or for Episodic Chronic Care.​
  • Assist in teaching 1:1 with patients for medication set up, dressing changes, or other home needs beyond clinic. Is able to do home visit if concern or question of safety in home.
  • Serve as a resource for providers, staff and patients for medical history, out of town/facility records and follow up.
  • Assist providers to determine care gaps/needs via Pre Visit Planning documentation.
  • Able to review chart and determine care gaps in care and follow up with patient and/or provider as needed to close care gaps (i.e. Hypertension, Color Cancer Screening, etc.)
  • Able to discuss mental health situations with patients including but not limited to depression, suicidal ideation, anxiety, and talking with patients/family with alcohol or drug use current or in past.

Non Essential Duties:
  • Assist nursing when needed for Refills, Triage or other tasks as trained.
  • Attend off site Coordinator meetings which enable most current education and knowledge of coordinator duties.
  • Participate in bi-weekly Care Team meetings which discuss high risk patients as well as overall wellness for clinic providers and patients.

Other Qualifications, Skills and Abilities:
  • Nursing licensure of RN or LPN
  • Ability to engage and teach patients
  • Phone etiquette
  • Ability to see "whole patient" environment, using social determinants to obtain needed services.
  • Willing to make home visits if needed for teaching, safety observation or other need.

Experience:
  • Prefer experience in home or community setting and/or patient coordination.
  • Current NE licensure for RN/LPN
  • Use of EMR in patient care



​Job Type:
Full-time

*Competitive pay and benefits*