The RN Care Coordinator functions, in collaboration and ongoing partnership with chronically ill or “high risk” patients, including Mental Health patients with care coordination needs, and their family/caregiver(s), Primary Care Provider, and other staff, Specialty providers, as well as other community resources in a team approach to:
• Promote timely access to appropriate care
• Increase utilization of preventive care
• Create and promote adherence to a care plan, developed in coordination with the patient, staff, primary care provider and family/caregiver(s)
• Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care and referrals
• Increase patient’s ability for self-management and shared decision-making
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction and reducing health care costs
• Increase comprehension through culturally and linguistically appropriate education
• Reduce emergency room utilization and hospital readmissions with patients identified as high resource use in these areas
• Enhances cost effectiveness by addressing care gaps and avoiding service duplication
• Utilize Community Health Worker at clinic site to evaluate progress toward care plan goals, or implementation status, when needed.

Principal Duties and Responsibilities
• Work with patients to plan and monitor care:
a) Assess patient’s unmet health and social needs
b) Develop a care plan, with patient, family/caregiver(s) and providers
c) Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner and facilitate needed changes
d) Create ongoing process for patients and family/caregiver(s) to determine and request care coordination support they need or desire
e) Evaluate outcomes of care
• Educate patient and family/caregiver(s) about relevant community resources
• 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
• Identify ‘high risk” patients utilizing available reports and recommendations by staff/providers.
• Appropriately, and routinely, document activities in the patient’s EHR and care plan
• Attending Care Coordinator training courses, webinars, to remain current on regulations, practices, etc.
• Provide feedback to, and participate in QA PDSA’s
• Provide patient medication reconciliation, and document in the EHR
• Develop and maintain data systems to track patient outcomes
• Identify gaps in care and implement methods to close gaps, including those attached to quality/outcome-based payments and bonuses
• Perform other duties as assigned

Required Skills or Abilities
1. Ability to manage and prioritize multiple tasks.
2. Working knowledge of EHR, Next Gen preferred
3. Proficient in Excel, Word and PowerPoint and ability to learn other computer programs.
4. Good organizational and self-management skills
5. Excellent verbal and written communications skills
6. Ability to communicate with a diverse range of people, from physicians to the patient population.
7. Demonstrates knowledge of, and adherence to patient’s rights, confidentiality and HIPAA guidelines and regulations
8. Knowledge of local community health and social welfare resources preferred
9. Ability to relate well to people from diverse ethnic and cultural backgrounds
10. Demonstrates working knowledge of PCMH processes and guidelines.

Required Knowledge, Experience or Licensure/Registration
1. Registered Nurse with current, unrestricted license in the state of Ohio
2. Previous experience in Community Health Center Care coordination and/or case management experience preferred.
3. Current CPR certification.
4. Knowledge of ICD-10 and CPT coding preferred