RN Care Coordinator, Population Health - FT

Registered Nurse, Population Health/Value Based Care

• Janesville, Wisconsin
• 30 hours/week, Full-Time, Benefits Eligible

• We offer a comprehensive benefits package that includes health and dental insurance, tuition reimbursement, retirement plan with a competitive matching contribution and paid time off. Mercyhealth offers several education assistance programs to support employees in their career advancement. Mercyhealth employees have access to our internal and external employee assistance programs, employee-only discount packages, paid parental and caregiver leaves, on-demand pay, special payment programs for patient services, and financial education to help with retirement planning.

The Value Based Care team works with patients to help them understand their current condition and treatment plans. While monitoring the patient's chart for vitals and recent updates the care coordinator collaborates with the appropriate medical teams to facilitate continuity of care for the patient. The care coordinators within Mercyhealth monitor and plan for all steps that assist patients from transitioning from the in-patient setting to the out-patient setting. We also assist the Primary care providers in managing their panel of patients by monitoring Care Gaps and Health Maintenance.

The RN Care Coordinator's primary responsibility is to oversee panel management for the primary care patients of the practice, to monitor chronic disease management and support providers in both. Duties assigned as appropriate for level of education and licensure. This includes both proactively working with patients to receive needed services, and to also assist patients within the clinic setting to meet their desired health goals.

Job duties assigned and distributed as appropriate for education and licensure level:

• Actively case manages assigned panel of chronic care patients.
• Oversees the prevention care reminder program for the practice's patients, ensuring that patients receive reminders of the need for preventive or disease management screening and testing.
• Leads the physician care teams in ensuring a smooth transition of care for patients seen or treated in an ED, IC or as an inpatient.
• Coordinates the process of determining the needs of various sets of individuals, including those identified chronic care conditions, using Epic and registry reporting to determine which patients are overdue for: care; services; or testing.
• Develops a community resource list of services available to patients and maintains collegial relationships with community resources agencies used most frequently.
• Contacts patients between visits via telephone, email or MyChart to check on self-monitoring, provide encouragement and support, and assess patient progress toward health status goals;
• Participates in the process of incorporating evidenced based diagnosis and treatment guidelines into the management of patient panels.
• Acts as a resource to assist the Clinic Partners with Medical Home patients who are non-compliant with their plan care.
• Introduces new patients to their disease care plan in the Medical home.

Requirements:

Graduate of an accredited nursing program.

BSN or upon hire BSN completion agreement for enrollment in an accredited BSN Completion Program

Licensed as an RN in the state of practice