Care Coordination Nurse

Job Description Summary:

The Care Coordination Nurse is responsible for the oversight of patient-centered care coordination in the areas of Chronic Care Management (CCM), Transitional Care Management (TCM), Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), or other care coordination programs as directed. The Care Coordination Nurse assures all service elements of the previous mentioned programs are met, documented and coordinated appropriately.

Essential Job Functions/Responsibilities:

1. Act as the liaison between each patient and the supervising provider between office visits, obtain all necessary information to remain compliant with Medicare standards, and satisfies Medicare or other insurance billing requirements.
2. Engage with an assigned caseload of patients (typically 200 patients per CCM nurse) in one or more of the Care Coordination programs, focusing on healthcare needs, care planning, medication adherence, facilitating appointment scheduling, remote patient monitoring and communicating with multiple providers using an electronic care plan.
3. Ensure that knowledge is always current regarding all hospital, home, and community-based services to ensure maximum utilization.
4. Work closely with all hospital, home, and community-based services as appropriate to ensure optimal alignment of resources with patient needs.
5. Manage any care transitions (referrals, discharges) by sharing information with the practice and with other healthcare providers involved in the patient’s care and will follow-up with patients on a timely basis after facility stays or referrals.
6. Educate the patient and give them the tools they need to monitor and manage their conditions and any medications, will also provide continuous care by reconciling the medication list with medications prescribed by other healthcare providers, and make sure the patient has access to medication, especially after care transitions.
7. Assume all other duties and responsibilities, as necessary.
8. Provide clinical expertise and oversight for management of medical conditions for care coordination patients. Acts as a resource to others.
9. Document all communication and coordination of patient contact in electronic health record including aggregation and clinical summaries.  Assure documentation includes tracking and time-stamping to support Medicare or non-Medicare insurance billing.
10. Complete and answer patient calls related to all Care Coordination activities.
11. Proficient use of electronic health records. Provides consultative support and training to staff in required elements, documentation and coordination.
12. Assure the electronic comprehensive care plan is created and maintained accurately per Medicare Regulations and organizational policies and procedures.
13. Establish and maintain positive relationships with all internal and external customers.
14. Act as a liaison for assigned patients with clients (physician office, facility, etc.).

Education and Experience:

• A nursing diploma, bachelor’s degree or associate’s degree in nursing, or the equivalent is required.
• A current, valid LPN or RN license in the state of Georgia is required.
• BLS certification is required
• 2-3 years of previous nursing experience is appreciated.
• Community Health or Public Health experience and GRITS training are desirable.
• Additional board certifications are favorable.
• Two (2) or more years’ experience in the care or case management of patients with chronic conditions.

Skills:

• Knowledgeable in the Medicare benefit for CCM, TCM, RPM and BHI is desirable
• Experience with eClinicalWorks and ability to quickly master new IT systems is desirable
• Bilingual (English and Spanish) abilities preferred
• Must be able to work in a seated position for extended periods of time.
• Must be well organized with an ability to set priorities and use time effectively.
• Excellent communication, leadership and customer service skills.
• Flexibility to handle a workload that fluctuates greatly based on team needs.

Working Conditions: The position has normal office working conditions with the absence of disagreeable elements.

Note:  The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified.  Furthermore, they do not establish a contract for employment and are subject to change at the discretion of the employer.