(Archived) Primary Care - Nurse Care Coordinator

JOB SUMMARY:

Primary responsibilities include participating in chronic disease management education, participating in data entry and manipulation to monitor performance improvement initiatives and working with leadership to improve access to health services, particularly for the uninsured. Care Coordinators achieve these goals by working with our patients to identify and modify psychological, behavioral, emotional and social factors important to maintenance of their holistic health and their ability to access care.

Ensures the delivery of exceptional customer service by putting all customers (internal and external) first and displaying:

• A healing focus
• A selfless heart
• A tireless resolve

MAJOR DUTIES AND RESPONSIBILITIES:

• Provides service for patients of adult and geriatric age groups.
• Healthcare Effectiveness Data and Information (HEDIS) Champion
• Pre-visit record planning ID HEDIS reminders, DXs to be updated, follow-up on diagnostic and consultation reports
• Responsible for referral and pre-authorization coordination. Coordinates patient appointments with network providers and follow up with providers to obtain timely reports.
• Provide patient education using and discuss selfmanagement goals with the patient and assists them in selecting appropriate goals to create an action plan
• Monitor and document goals selected and follow-up with patient by phone, email or in person to determine if goals are achievable and provide assistance to the patient when needed in how to achieve their goals.
• Facilitates disease management support groups.
• Facilitate connections to community support groups and resources
• Maintains a wellness bulletin board
• Maintains contact with patient while hospitalized
• Post discharge plan and follow-up and coordination.
• Maintains a safe environment of care for patient and staff by reporting any unsafe condition, equipment, or activities to the appropriate personnel.
• Participates in multi-discipline team conferences and mandated service training programs.
• Participates in the development and implementation of corrective action plans to address departmental and operational deficiencies
• Identifies and reports equipment and information systems malfunction with the IT Department.
• Checks and maintains adequate amount of equipment and supplies.
• Maintains records and correspondence in orderly well kept files
• Informs supervisor of any management or operating problems that may affect quality and standards of patient services.
• Provides comprehensive monitoring of all patient cases to ensure timely and thorough medical treatment and access.
• Demonstrates respect for the privacy and confidentiality of patients medical records and visits.

Concentra's Data Protection Commitment
* Concentra is committed to protect patient data and to ensure privacy of personal and medical information.
* Every Concentra colleague has the responsibility to adhere to data protection principles.
* If a colleague's role includes handling or processing sensitive data, role-specific policies and requirements apply to ensure the protection of patient information.