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Form of workJob Description
Position Summary and Objectives
The Population Health Nurse Care Coordinator is responsible for the successful outreach, scheduling, and care management of assigned patients to meet Population Health and Value Based contract goals. The Population Health Nurse Care Coordinator will establish and maintain effective relationships with physicians, clinical staff, patients and caregivers, payers, and community resources. The Population Health Nurse Care Coordinator will utilize various computer programs and platforms to gather and analyze data related to the Population Health program goals and objectives. This position is a hybrid remote/on-site schedule.
Responsibilities
- Utilize motivational interviewing techniques to build trust, clarify patients’ goals, identify reasons for ambivalence and guide patients to take positive steps in managing their health.
- Review target patient lists or disease registries to identify high- and emerging-risk patients, evaluating appropriateness for enrollment in Chronic/Principal Care Management programs.
- Perform Chronic/Principal Care Management of assigned caseload, including, coordinating medical treatment, completing assessments, developing care plans, monitoring medication compliance, and effectively communicating with patient’s primary care provider and staff as needed to meet patients’ needs.
- Utilize ADT reports and payer portal data to complete Transition of Care outreach (TOC phone calls) within established guidelines, scheduling patients for appropriate follow-up with PCP/Specialist accurately and timely. Document outreach efforts and outcome accurately and timely as required for gap closure.
- Monitor Medication Adherence gap reports daily. Contact patients to identify potential barriers to medication compliance, provide medication education and interventions to promote adherence to medication regimen.
- Facilitate connecting patients with Medication Therapy Management programs with Medicare Advantage programs as required by MA contracts to meet MTM quality measure.
- Function as Remote Patient Monitoring coordinator, responsible to receive and resolve RPM escalations from RPM provider during clinic hours. Identify and recommend appropriate CCM/PCM and TOC patients for referral to RPM program as appropriate.
- Identify patient barriers to completing recommended preventative screenings, annual wellness visits, and follow up care and assist patients with overcoming barriers.
- Function as subject matter expert in community resources to assist patients with identified socio-economic barriers to care. Maintains database of community and payer resources to assist patients.
- Maintain accurate records and report to manager, director and others as required.
- Contribute to closing gaps in care.
- Participate in meetings and collaborate with both internal and external stakeholders to identify and implement effective strategies to meet program goals.
- Perform other duties as assigned.
Essential:
- Accountability: accepts ownership of job roles and specific assignments; works independently, connects personal work results to accomplishment of team and organizational goals.
- Able to work in a team environment focused on value-based patient care. Has broad clinical knowledge to effect positive patient outcomes.
- Able to work accurately and effectively in a fast paced, high stress environment. Able to multi-task.
- Able to collect data, prepare summaries and reports.
- Able to communicate effectively with providers, staff, external stakeholders, patients, and families/caregivers.
- Able to use principles of motivational interviewing resulting in positive change in patient’s behavior.
- Able to accept change and adapt in a positive and productive manner; handle unexpected situations and changes in direction calmly and with confidence.
- Strong computer and keyboarding skills. Proficient in Microsoft Word, Excel, PowerPoint and EMR.
Experience:
- Required: LPN with current Indiana license. One year of professional nursing experience in a clinic setting.
- Preferred: RN with current Indiana license.
- Experience with HEDIS or Value Based Care preferred.
Work schedule may transition to 50% remote and 50% on-site upon successful completion of orientation and training period.
Reports to: Manager, Population Health and Value Based Care
Location: 303 S. Nappanee Street, Elkhart, Indiana 46514
