Job Type:RegularScheduled Hours: 40Job Summary:Reports to Manager of Care Coordination, works collaboratively with providers, (interdisciplinary staff) and clinical associates to support patients with chronic conditions and/or complex needs according to guidelines established by (care transition) the primary care and other clinical programs such as PQRS, PCMH, etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns.Job Description:Job Title: Care Coordinator - RNNon-ExemptJob Code: 140192PRIMARY PURPOSE:Works collaboratively with providers, (interdisciplinary staff) and clinical associates to support patients with chronic conditions and/or complex needs according to guidelines established by (care transition) the primary care and other clinical programs such as PQRS, PCMH, etc. Facilitates effective communication, coordinates services, address barriers, and provides education and guidance for patients related to current health concerns.BENEFITS:No Nights, Holidays, or WeekendsPaid Time OffMedical, Dental, and Vision403b with MatchOpportunity for Career GrowthDUTIES & RESPONSIBILITIES: Understand and uphold SEP’s Mission, Vision, and Values.Comply with all applicable laws and regulations.Documents in chart appropriately utilizing care management documentationProvides patient care through collaborating with patients, providing education and clear direction to the patient and address patient concerns regarding care. The RN engages in critical thinking to meet patient needs.Identify patients with chronic disease, rising risk concerns, social, financial or educational needs for care management services.Respond to provider referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or blood pressure, Mental Health Integration referral, complex needs)Provide education and pre-printed, SEP approved educational materials as needed, or at provider or patient requestWork collaboratively with patients to assess needs and develop a patient education plan of careAnswer clinical questions related to patients’ chronic health conditionsProvide group education for established patientsMust understand professional boundaries and appropriately refer diagnostic questions to MDRefer patients appropriately when needs for mental health, pharmacy, social work, respiratory therapy etc. are identifiedWork face to face or telephonically with patients as needed.Ensures complete and accurate information in the Electronic Health Record.Forward written physician orders for treatmentAssess patient for additional needs, develop nursing plan of care and contact physician for order-dependent itemsMaintains adequate level of resources for care coordination.OSHA and HIPAA compliance.Assists with completion of patient requests in a timely manner.Timely and accurate complete charting of all patient informationOther duties and responsibilities as assigned are complete in a timely and accurate manner.Maintain good working relationships communications with the all interdisciplinary team members, management and utilization review staff for coordination of care and care transitionsWork with providers, interdisciplinary staff and office staff to identify appropriate patient population for advance care planning.Work directly with patient to educate, provide resources and manage their disease processesManage and perform home visits with patients as needed if a component of care management expectations.Attend meetings as required.EDUCATION:Current State Allied Health License required, RN.Current Driver’s License in good standing and reliable and insured transportationDegree in nursing or other related clinical fieldCare Management Certification preferredYEARS OF EXPERIENCE:Three to four years medical field experienceDemonstrated knowledge of anatomy and physiology, pharmacology, etc.Ambulatory and/or care management experience preferredLICENSES AND CERTIFICATIONS:Current state Allied Health license.REQUIRED SKILLS AND KNOWLEDGE:Ability to manage and prioritize multiple tasks.Knowledge of electronic Health Records – (EPIC)Knowledge of Excel, Word, Outlook and PowerPoint and the ability to learn other computer skills as needed.Good organizational skills.Work professionally with doctors, hospital administration and management, SEP associates and the public.Organized, neat and self-motivated.Warm personality with concern for others.Excellent verbal and written communication skills.Excellent interpersonal skillsAbility to affect changeAbility to perform critical analysisSelf-directedWork well telephonically as well as face to faceCan work autonomouslyBe familiar with motivational interviewing with patientsPositive attitudeQuest for learning and excellence.Demonstrated ability to work successfully in a team-based decision-making culture.Demonstrated ability to work independently resulting in effective outcomes and on-time performance.Experience in planning and coordinating multi-disciplinary communications strategies, strategic initiatives, and events.Must respond and follow through to requests from customers promptly.Must work carefully and precisely with attention to detail.Must utilize resources wisely.Performs duties willingly and with initiative. Shares necessary information so co-workers can do the same.Cooperates with other departments and work groups.OTHER REQUIRED SKILLS AND KNOWLEDGE:Previous Quality Assurance experience preferred.FLSA Status: Non-ExemptRight Career. Right Here. If you have a passion for taking care of the community and are interested in Healthcare, you will take pride in the level of care we provide at St. Elizabeth. We take care of patients and each other.