Registered Nurse (RN) - Home Health
Guthrie Health
Big Flats, NY

RN Care Coordinator - PCMH (Patient Centered Medical Home Initiative in Primary Care)- Full Time Day

$25,000 Sign On Bonus For Qualified RNs! Position Summary: Care Coordinator in Primary Care will serve as a practice support in the Patient Centered Medical Home development and process. The position is an integral part of the Patient Centered Medical Home Team. The PCMH Care Coordinator has the responsibility and accountability for coordinating the medical management of patients, using an outcomes‐based approach. In collaboration with other members of the healthcare team, the Care Coordinator identifies at risk patients, develops a plan of care, and coordinates care with the patient's involvement. Will work with physicians and other patient care providers as he/she supports the PCMH initiative in meeting quality process and performance objectives through data collection, data analysis and process outcome evaluation. Education, License & Cert: Licensed Registered Nurse with 5 years' experience, preferably in an outpatient/ambulatory setting. Bachelor's Degree in Nursing or related field required. With an employment agreement, will consider applicant who is actively pursuing their bachelor's degree. Master's Degree preferred. Licensed Nurse Practitioner considered. Licensure: The Care Coordinator must be licensed in both New York and Pennsylvania. The applicant must have a current license as a Professional Registered Nurse in their state of practice prior to position start date. Additional state licensure must be obtained within 6 months of hire. Patient outreach and contact will be limited to those patients living in the state of current licensure until dual licensure is obtained. Experience: A minimum of five (5) years relevant clinical experience who demonstrates leadership and autonomy in nursing practice. Preferred experience with PCMH process, care management/utilization review, and payer knowledge. Fast paced ambulatory care experience preferred. Essential Functions: 1. Support Care Management functions in Primary Care Practices a. Actively manages a panel of high‐risk patients using motivational interviewing, shared decision making, and goal setting to increase patient/family engagement. b. Uses technology, such as tele‐visits and remote monitoring capabilities, to engage patients and monitor chronic health conditions. c. Measures improvements in process and quality of care through evidence‐based guidelines. d. Provide Transitional Care Management (TCM) following an inpatient stay for all identified patients. e. Collaborates with patient, physician, and other care team members in assessing the patients progress toward individual health care goals. f. Provides follow‐up information for the patients indicated to ensure compliance with recommendations, medication, lab/x‐ray, specialist visits, PCP visits, dieticians, CDE, etc. 2. Supporting the PCMH initiative at the practice level through involvement with quality improvement initiatives, participating in PCMH/Population Health meetings, and educating on best practice models as needed. 3. Support the primary care practice with the use of technology, including Microsoft and EPIC Software. Functionality would include reporting Workbench, Patient Outreach (eGuthrie, Health Maintenance, Care Everywhere, EPIC Care Link) and Disease registry tools. 4. Is an active member of the Care Coordination team through participation on regular team meetings and regional Case Management meetings, as well as leading discussions and teachings to practice level staff on chronic disease management and high‐risk patient management. Other Duties: 1. Travel for this position may be required. 2. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures. 3. It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position. Pay Range: The pay range for this position is $31.00 - $47.86 per hour.