Care Coordination RN

• 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.

• 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.

Based on experience and at the discretion of the Chief Executive Officer.