Care Coordinator – Bristol and Tazewell

• The candidate will work on a multidisciplinary healthcare team in a primary care setting and focus on coaching and coordination of care for high-risk, chronically ill patients and those with co-morbid conditions.
• The candidate will work alongside the providers and office staff in a Patient-Centered Medical Home (PCMH) environment, potentially serving multiple locations.
• The candidate will provide care coordination services for patients and assist the practice to implement systems changes to improve quality and access to care, and reduce hospital admissions, ER visits, and overall healthcare costs.
• The candidate will actively participate in multidisciplinary patient-centered team meetings and develop and strengthen community partnerships.
• The candidate will assist providers and other care team members in implementing processes for best practices for preventive services, chronic care and disease management.
• The candidate will utilize EMR /registries reporting to identify high-risk patients, proactively engage patients, ensure they maintain a connection to the medical home, conduct pre-visit planning with providers such as printing daily huddles sheets and risk assessments and prioritize patient follow-up.
• Work collaboratively with providers and the care team to ensure development of the plan of care in partnership with the patient and family, including all appropriate preventive and disease-specific screenings, interventions, treatment goals including self-management goals

Qualifications/Experience:

• Certification of practice as a Registered Nurse, Licensed Practical Nurse
• Certified Case Management (CCM) certification*. Preferred as available
• A minimum of five (5) years’ experience in health center setting
• Proficient computer skills
• Ability to maintain confidentiality
• Ability to maintain registries, records and files
• Ability to communicate in person or on the phone with staff, patients, and general public
• Must be qualified in Basic Life Support techniques and CPR.
• Familiarity with community resources and social service resources to assist patients with social needs.
• Experience in primary care, rehabilitation, skilled facility, home care, or managed health plan.
• Discharge planning or related experience.