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.
Coordinate health care services for patients through assessment of their chronic
conditions and/or other health care needs.
Complete HRA (Health Risk Assessment) to develop Individualized Care Plan (ICP).
Document ICP and care coordination in case management module database (NextGen, EZ Cap,
Utilize the case management process to guide service delivery throughout the health
care continuum to ensure quality care delivered in a most efficient and
Engaging patient and their care givers in understanding and setting self management
plans in a culturally and linguistically appropriate manner.
Facilitate and coordinate services to develop patient-centered individualized
integrated self management plans including self management and outcomes
Support the PCP to implement the integrated plan to achieve desired outcomes and to
satisfy contractual/regulatory requirements.
Collaborate with various health care providers across the care continuum to ensure
that patients are effectively managed and that health care needs are met.
Refer patients to the corporate case management team based on acuity level 3
and/or complex case managed needs.
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
Define and evaluate desired and actual outcomes in collaboration with the IDT
Facilitation and recommendation of cost effective alternatives to care provision.
Participate in patient-centered interdisciplinary care conferences, Clinical Quality
Improvement Committee and Utilization Management committee as needed.
Performs other related duties as assigned.
Skills and Abilities:
Excellent customer service skills and
ability to resolve complex customer service issues and exercise conflict management.
Ability to read, write and speak in a clear,
accurate and professional manner; includes active listening skills and
understanding medical terminology.
Ability to complete basic/intermediate math
computations and medical math conversions.
Proficient in beginning/intermediate
computer skills and typing.
Excellent follow through skills,
multi-tasking, prioritization and attention to detail.
Knowledge of the Case Management Process,
Chronic Care Model and Patient-Centered Medical Home Model (PCMH).
Must be able to apply critical thinking skills and make sound judgment at all levels throughout the patient’s continuum
of care and make necessary referrals on behalf of P/P/C
Knowledge of regulatory requirement, health plan contracts, governmental benefits and community resources.
Ability to apply critical thinking skills while performing daily responsibilities
Excellent interpersonal skills reflecting
clarity, diplomacy and communicates accurately and effectively with all levels
of staff and management.
1. Current, active, and unrestricted CA RN license
2. Minimum of 3-5 years of acute care clinical experience required; 2 years or more of
managed care experience and case management experience with
outpatient/ambulatory focus preferred.
3. CPR/First Aid certificate required.
4. Case Management Certification (CCM) preferred.
depending on location preferred.
We promote a comprehensive continuum of care, assisting individuals and their families from birth through the senior years, regardless of...