MUSCP - Remote Patient-Centered Medical Home RN Care Coordinator - Midlands

The role of the Patient-Centered Medical Home (PCMH) Care Coordinator III is a nurse that works collaboratively with the physicians, staff and other health care professionals to actively facilitate health care delivery and promote care team communication for an assigned patient population ensuring appropriate care is provided. This position will be remotely based, in the Midlands area. This position will be required to round in clinics 1-2 days per month.

Identifying patients that qualify for care coordination: not meeting clinical goals and quality measures (i.e. hypertension and diabetic control) for CCM pts, overdue for visits, labs, or referrals and arranging for follow-up services as appropriate for CCM pts, chronic care management (CCM), identify gaps in care and respond with appropriate action to correct. TCM coverage as needed. Utilizes Epic registries and reports in accordance with process (i.e. CCM-weekly & daily, quality measures) to identify patients and needs. Outreached to patients identified for care coordinator services (i.e. CCM, quality measures) & documents attempt (s) & completion. Scheduled services and places referrals in accordance with patient need (s) (i.e. vaccine, labs, appointment, mammogram, etc.) Follow up as appropriate to track data. Accurately maintains 100% of data received. Communicates effectively and professionally with patient (s), care team (s) and providers to provide support for continuity of care between patient, care team, and assigned providers Compiles and summarize information for quality measures and projects. Attend 80% of staff meetings. Maintains communication with providers & care team members (i.e. Epic inbox message, email, phone, office schedule, in person) Identify patient needs and/or barriers (psychosocial and other) to care and coordinate patients/families contact with community resources. Completes & documents accurate information gathering of data. Completes Epic & community referrals as needed. Communicates & follow up of identified barriers to the appropriate care team member/resource. Other duties as assigned.