RN Care Coordinator

This individual will coordinate outpatient hospital follow-up care, complete annual Medicare Wellness Visits per CMS (Center of Medicare & Medicaid Services) guidelines, and provide high-quality diabetes education.

II. Roles & Responsibilities

Care Coordination

Coordinates care of patients with caseworkers at hospitals by scheduling hospital follow-up care appointments in a timely manner. Contact patients to ensure they are aware that a follow-up visit is scheduled.

· Monitors ER visits and hospital admissions to determine if they were avoidable ER visits or readmissions to the hospital, utilizing reports of hospital admissions from insurance companies.

· Maintains a log of all patients scheduled for hospital follow-up care, including the diagnoses of admission and the status of the follow-up appointment.

v Medicare Wellness Visits

· Schedules patients for their annual Medicare Wellness Visit every year.

· Completes and documents all annual Medicare Wellness Visit requirements following CMS (Center of Medicare & Medicaid Service) guidelines.

· Interview patient and family members to obtain information about home environment, family relationships, and health history to document in EMR.

· Educate patients on depression by doing depression screening, provide risk management assessments for falls, and review risk factors for patients on overmedication usage.

· Reviews CDSS alerts. Schedules recommended health maintenance screenings per UDS guidelines, including but not limited to annual lab screenings, colorectal screenings, DEXA scans, and mammograms. Ensures reports are entered into the EMR following completion of test.

· Administers recommended vaccinations per CDC guidelines.

v Diabetes Education

· Schedule diabetes education appointments from on-site provider referrals and use UDS reports to identify patients with A1C greater than 9%.

· Maintains documentation on all patients receiving diabetes education, including patient information, goals, progress, and outcomes.

· Assists provider with prior authorization of diabetic medications, glucometers, and glucometer supplies as needed.

· Provides education on diabetes medications and utilization of diabetic testing supplies, including but not limited to CGM (continuous glucose monitoring) systems.

· Completes diabetes retinal exam in office annually.

· Acts as a patient advocate. Focuses on individual, complex needs of patients in a supportive role.

· Attends and participates at in-person conferences/webinars to further diabetes education knowledge.

· Participates in the development and selection of patient education materials and services.

· Provides a multi-disciplinary approach to treatment plan, coordinating with other medical staff.

· Explores available resources and services. Consult with other caregivers.

· Maintains current knowledge of community resources and makes referrals that adequately and appropriately utilize these resources. Provides updated information to other clinic staff regarding community resources.

· Offers in-service education programs and functions as a resource to clinic staff and the community as needed.

· Attends all mandatory staff meetings.

· Assists in other areas of the office in low staffing crises.

· May be asked to assist with other tasks within their scope of practice.

· Other duties as assigned.

III. Qualifications & Education Requirements

A bachelor’s degree in social work, nursing, or a related field is preferred. Associate degree in Nursing, minimum qualification.

At least two (2) years of case management experience preferred. Previous EMR experience preferred.

IV. Knowledge, Skills, & Abilities

Knowledge of community resources and referral agencies. Knowledge of group dynamics. Skill in interviewing and communicating to elicit information and cooperation from patients. Skill in establishing and maintaining effective working relationships with providers, patients, staff, and the public. Ability to write reports and document patients’ progress.

V. ORGANIZATIONAL VALUES

· PCSG is a values-based organization. All our decisions, actions, and conduct are guided by our core values:

o Compassion: We believe in acting with empathy and understanding, valuing the well-being of our colleagues, patients, and community.

o Integrity: We uphold the highest standards of honesty and ethical conduct.

o Teamwork: We foster a collaborative environment where everyone's contributions are valued.

o Accountability: We take responsibility for our actions and their outcomes.

o Respect: We treat everyone with dignity and consideration.

VI. Physical Demands

Requires sitting for long periods of time. Occasional bending, stretching, or lifting. Contact with individuals with communicable diseases. Requires the ability to work under stressful conditions. Ability to hear a standard range of voice. Ability to prepare written reports and use telephone and other office equipment such as copier and fax.

VII. Working Conditions

Normal office environment.

Job Type: Full-time

Pay: From $60,000.00 per year

Benefits:

• 403(b)
• 403(b) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Health insurance
• License reimbursement
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift

Work Location: In person

Salary : $60,000