OVERVIEW: The primary responsibility of this position is to manage care for the patients of the primary care practice to promote effective patient education, self-management support, increased adherence to recommended preventive care, and timely health care delivery. This includes developing and monitoring care management processes and quality improvement workflows, and providing support to primary clinical teams with these efforts. It also includes identifying the high acuity patient population and working to ensure care management for this patient population.

RESPONSIBILITIES:

Work with all clinical teams as a resource on care management of all patients of the practice
Perform follow up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission
Involve the patients in activities to improve their health and educate the patients about self-management tasks they can undertake to gain greater control of their health status
Identify and effectively utilize community resources to meet the needs of patients/families
Facilitate patient access to community resources as appropriate
Promote patient self-management and empower patients/families to achieve maximum levels of wellness and independence
Collaborate with the patient, physician, and other care team members in assessing the patient’s progress toward individual health care goals, and assess barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments
Participate in team meetings and departmental and organizational committees as applicable
Demonstrate ability to work independently, while collaborating with other team members
Develop, monitor, and refine workflows and processes with the goal to increase patient adherence to guideline concordant medical care
Review utilization and quality reports routinely and scan for gaps in care to identify patients needing the additional support of care management
Perform all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing
Perform medication reconciliation for all care transitions
Provide coverage across the organization as needed
Work collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures
Perform any additional tasks requested by Office Manager or Physicians

COMPETENCIES:

Good organizational skills to handle multiple priorities while remaining professional and calm
Ability to work with many diverse people
Excellent written and oral communication skills
Strong level of confidentiality due to the sensitivity of materials and information handled
Must able to make suggestions on workflow or system efficiency and effectiveness
Ability to work independently and be self-directed and flexible
Ability to prioritize
Ability to perform functions with minimal supervision
Ability to work at a high-volume level of accuracy
Ability to communicate effectively with providers and medical staff
Computer skills proficient to expert
Problem solving skills
Proficiency in medication indications and side effects
Understanding of medical tests and requirements for test as to provide the patients with appropriate information

QUALIFICATIONS:

Active Arkansas Registered Nurse or Licensed Practical Nurse licensure required
Relevant experience in care management or quality improvement programs preferred
Minimum of three years of experience as a licensed nurse in a primary care setting preferred; experience in care coordination preferred
Experience with eMDs Solution Series EHR software desirable

Please note this position is posted on behalf of our partner practices. This individual will be working at the specific practice that is mentioned in the above details and will not be a direct employee of Aledade, Inc. so will therefore not be eligible for the benefits available to Aledade employees.

This job is no longer accepting applications

See open jobs at Aledade.See open jobs similar to "Care Coordinator - Quality Program Specialist" Venrock.

See more open positions at Aledade

Privacy policy Cookie policy