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Care Team Coordinator / Catawba Valley Medical Group / Full-Time/ (Posted 06/18/2021)
Works directly with the Quality Improvement Manager to accomplish and sustain Patient Centered Medical Home (PCMH) practice medical home and Accountable Care Organization (ACO) designation. Provide subject matter expertise to support implementation and maintenance of Care Coordination/Health Navigation/Quality programs. Assist with training program that ensures Care Coordination team/Health Navigators meet and maintain minimum core proficiencies throughout their employment. Directly supervises the daily functions of the Care Coordination/Health Navigation team. Generates, reviews, and disseminates performance improvement reports throughout the network. Responsible for ensuring complete and accurate data capture/documentation by Care Coordination team/Health Navigators, coordinating their efforts, ensuring manageable caseloads, and providing clinical guidance and support. May provide back-up coverage as necessary for the department. Ensures successful care coordination though high quality, cost effective, efficient, patient-centered outcomes. Promotes clear communication among the care coordination/health navigation team. Ensures recommendations given by the physician or mid-level provider are followed when reviewing the patient���s care plan. Manages the coordination of care that includes chronic disease management, and population management with emphasis on wellness promotion, disease prevention and patient engagement. Provides resources for patient/caregiver education to the Care Coordination team focused on care plans to ensure patients/caregivers understand every aspect of their care and wellbeing. Communicates with community organizations, health plans, facilities and specialists as needed to ensure continuity of care. Follows an evidence-based approach to self management support, such as patient coaching and motivational interviewing.
Education and Credentials:
Bachelor���s degree in Nursing. BCLS certification from the American Heart Association required within three months of employment date.
Relevant professional certification(s), such as Case Management, Disease Management, Health Coaching, Guided Care Nursing.
Five years of nursing experience. One year of Care Coordination experience with population management reports and data interpretation. Management and training experience. Given training and on-the-job experience, incumbent should be proficient in the basic aspects of the position within three months of employment date.
Experience as a nurse leader. Experience in outpatient primary care, acute care, care coordination and case management.
Hickory, North Carolina, United States