Care Coordination Registered Nurse (CCRN)
Summary: The CCRN renders professional care to patients who are transitioning from one care setting to another and patients who are living with complex, chronic health conditions.
Essential Job Functions:
- Inpatient Admissions Coordination
- Contacts patients transitioning from inpatient to outpatient settings about ongoing needs and appropriate follow-up activities
- Monitors the Aledade app and inpatient facility interfaces for notifications regarding patients who have been discharged from inpatient settings
- Obtains and reviews complete patient discharge information from the inpatient facility
- Reconciles all patient medications and prescribed medical equipment in the electronic health record
- Documents date of discharge, date of contact, admission diagnosis/problem, current condition, need for referrals or testing, and additional needs such as services or equipment, including if the patient has filled discharge medications
- Completes telephone contact to transitioning patients within two (2) business days of inpatient discharge.
- Documents results of telephone contact in the electronic health record
- Schedules a follow-up appointment with the patient’s NMPHC primary care provider within 7-14 days of discharge
- Educates patient on how and when to contact the health center if there is any change in condition
- Emergency Department Coordination
- Contacts patients who have an Emergency Department discharge
- Monitors the Aledade app and inpatient facility interfaces for notifications regarding patients who have been discharged from emergency departments
- Obtains and reviews complete patient discharge information from the emergency facility
- Completes telephone contact to patients within 7-days of emergency department discharge
- Documents the outcome of the call in the Aledade app and electronic health record.
- Schedules follow ups appointments as needed.
- Educates patient on how and when to contact the health center for non-emergent care, especially after regular business hours
- Chronic Care Management (CCM)
- Maintains registry of CCM enrolled patients
- Conducts minimum of one twenty-minute telephonic or in-person counseling and education per month to each CCM patient in registry
- Completes documentation in electronic health record and Aledade application
- Provides patient health counseling, education, and instruction for management of chronic disease
- Performs other duties as assigned by the Medical Provider or Director of Value-Based Care as permitted by documented training authorized by the Chief Medical Officer
- Attend in-service classes, workshops, meetings and seminars as scheduled.
- Maintain professionalism in appearance, communications, and interactions with others.
- Notifies supervisor/clinic in a timely manner if unable to attend work. Fill out the appropriate forms as directed for annual/sick leave time.
- Participate in health fairs or other programs assigned by the Chief Executive Officer.
- Other reasonable duties as assigned by the Chief Executive Officer.
Primary Work Location:
Benton Medical Center, Ashland, MS
- Graduate from an accredited School of Nursing
- Current license in Mississippi as a Registered Nurse
- Minimum 1-3 years' work experience in a healthcare setting involving patients with complex chronic disease states (preferred)
- Bilingual Spanish (preferred)
- Must be capable of working in the prescribed setting and possess good interpersonal skills to function independently as needed for good patient care/service and teamwork.
- Must be highly motivated, result-oriented with strong communication, organizing, and time-management skills
- Must possess clerical and technical skills necessary for documentation in the electronic patient record.
Direct Supervisor: Director of Value-Based Care
Direct Reports: None
Based on experience and at the discretion of the Chief Executive Officer.
North Mississippi Primary Health Care, Inc. is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.
Submit Your Application
You have successfully applied
- You have errors in applying