Primary Care Coordinator (10834)

JOB SUMMARY

The Nurse Care Coordinator will utilize care coordination, case management, and resource management with the purpose of improving the patients health, reducing healthcare costs, and improving the patients healthcare experience. The Nurse Care Coordinator will collaborate with the patients Primary Care Provider, the NOTCH clinics, outside entities, and community health partners to help the patient achieve their healthcare goals. The Nurse Care Coordinator will focus on medical, mental health, substance use, and social determinants of health. The Nurse Care Coordinator will use EMR functionality, NOTCH Partnerships, and referrals to identify high risk/high need patients,

ESSENTIAL DUTIES AND RESPONSIBILITIES

Interacts with patients and members of the care team to provide a range of care services. Specific duties and responsibilities include:

• Act as the NOTCH liaison to 3rd party payers and be responsible for medication authorizations
• Scan and route incoming documents to the appropriate NOTCH employees
• Track diagnostic imaging orders
• Perform transition of care phone calls
• Medication reconciliation
• Collaborate with community partners including but not limited to: home health, designated agencies, skilled nursing facilities, long term care facilities, assisted living facilities, Age Well, Support and Services at Home (SASH), and hospitals
• Participation in NOTCH Patient Centered Medical Home initiatives
• Patient education
• Disease management support
• Manage a caseload of patients
• Engage patients in self-management action planning
• Provide health coaching
• Assist patients with social determinants of health, including but not limited to: housing, food, and transportation to medical appointments
• Update the medical record including medications and medical history
• May execute organization approved standing orders per written procedure
• Coordinate care with specialists and external disease management organizations
• Comply with all documentation requirements, including progress notes, computer data entry, releases of information, treatment and case management plans
• Participate in Quality Improvement projects under the direction of the Care Coordination Team Manager. Participation may include: participating in a new process or change, providing feedback to the tests of change, and providing suggestions for the next tests of change
• Assesses own educational needs in terms of knowledge necessary to the job position and works with the supervisor to create a professional development plan to address knowledge gaps
• Participate in training sessions
• Participate in community events
• Conducts home visits for care coordination, case management, and duties within the scope of practice as determined by the Vermont State Board of Nursing
• Performs other functions or duties as assigned