RN Home Clinical Care Coordinator

Medica Talent Group is excited to share this Direct Hire Placement opportunity with you! Our client, a reputable non-profit health agency is seeking to hire an RN Patient-Centered Medical Home Clinical Care Coordinator to join their fast-growing team. If you are interested in joining an organization that is patient-driven and comes with experience clinical care and case management experience providing excellent treatment to your patients we invite you to apply. Apply to learn more or reach out to mvillagran@medicatg . com or call/text 714-987-0266 Overview The Nurse, (RN) Patient-Centered Medical Home (PCMH) Clinical Care Coordinator will provide daily care coordination, case management, coaching, consultation and intervention to patients with one or more chronic diseases. Responsible for identifying said population via provider/clinic referral, utilization management referral, disease registry reporting mechanisms and patient self referral. Works as part of an interdisciplinary care team including but not limited to coordinating patient services such as social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc. Effectively collaborates with all members of the healthcare team to include members of the interdisciplinary care team, the member’s family and member and with the physician in the clinic. Provides disease specific educational support and in-services to clinic staff. If an advanced practice degree is current and held by the Clinical Care Coordinator, the role may include disease management specific patient encounters as agreed upon between said nurse and the clinic Medical Director. This position will report under a matrix structure to the Manager Case Management, Clinic Administrator, and Clinic Medical Director. Responsibilities: 1. Coordinate health care services for patients through assessment of their chronic conditions and/or other health care needs. 2. Complete HRA (Health Risk Assessment) to develop Individualized Care Plan (ICP). 3. Document ICP and care coordination in case management module database (NextGen, EZ Cap, etc.). 4. Utilize the case management process to guide service delivery throughout the health care continuum to ensure quality care delivered in a most efficient and effective manner. 5. Engaging patient and their care givers in understanding and setting self management plans in a culturally and linguistically appropriate manner. 6. Facilitate and coordinate services to develop patient-centered individualized integrated self management plans including self management and outcomes goals. 7. Support the PCP to implement the integrated plan to achieve desired outcomes and to satisfy contractual/regulatory requirements. 8. Collaborate with various health care providers across the care continuum to ensure that patients are effectively managed and that health care needs are met. 9. Refer patients to the corporate case management team based on acuity level and/or complex case managed needs. 10. Monitor ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria – Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty. 11. Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan requirements. 12. Assist with composing medical director denials to meet language requirements set by ICE/Health Plan requirements. 13. Perform and document patient telephonic and/or person-to-person risk assessments as needed. 14. Define and evaluate desired and actual outcomes in collaboration with the interdisciplinary team. 15. Participate in patient-centered interdisciplinary care conferences, Clinical Quality Improvement Committee and Utilization Management committee as needed. 16. Performs other related duties as assigned. Qualifications: 1. Current, active, and unrestricted registered nursing license or certification in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline required; Bachelor’s degree in social work, nursing, or another health or human services field with the appropriate licensure preferred. 2. Minimum of 3 years of acute care clinical experience or public health nursing required; minimum of 2 years of managed care experience in case management with focus in inpatient and/or outpatient ambulatory care preferred. INDMED