Role Description The RN care coordinator is a trained professional that helps patients manage their chronic conditions by calling patients monthly. Monthly calls will include:

• Assessing current health status
• Educating patients about their chronic conditions
• Answering questions and acting as a resource between the patient and the provider
• Addressing any urgent patient needs
• Following up on any changes in patient condition

Job Duties & Responsibilities Include but are not limited to:

• CCM monthly calls or verbal enrollments
• Other services such as Health Risk Assessments, Transitional Care Management, Remote Patient Monitoring, etc.
• Communicate with patients and family members about their chronic conditions, medications, quality measures, barriers to care, and practice-specific requests
• Communicate effectively with providers, staff, and other healthcare professionals
• Promote adherence to a care plan developed in coordination with the patient, primary care provider, and family/caregiver(s)
• Increase patients’ ability for self-management and shared decision-making, and assist patients in reaching established goals
• Medication reconciliation
• Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing healthcare costs
• Represent CCS in a caring and professional manner to providers and other healthcare professionals
• Comply with organizational guidelines and healthcare laws and regulations, including CMS guidelines
• Be flexible and a team player
• Maintain expected call volume (see Call Expectations Policy)

Qualifications

• Unencumbered active compact license (RN), or a California RN license
• Must live in either MST or PST time zone
• Active BLS certification
• Ability to plan and organize time effectively, work independently, and show good judgment
• Excellent problem-solving, clinical reasoning, and critical thinking skills
• Ability to communicate effectively both verbally and in writing
• Knowledge of CCM regulations and of CCM billing requirements
• High proficiency in working within EHR systems
• Demonstrated leadership skills, including the ability to guide, motivate, and support team members
• Operational knowledge of Google Suite, Atlas, and other required software

Home Office

• Care coordinators must have a HIPAA-compliant workplace that is free of any distractions
• The workplace must be in a room with a locked door to prevent accidental PHI disclosures
• The home office must have high-speed internet and a CCS-approved computer with two monitors

Physical Demand Includes but is not limited to vision, hearing, repetitive motion, typing, and extended sedentary viewing of a work environment computer screen. Reasonable accommodations may be made, with advanced notice, to enable individuals with disabilities to perform the essential functions and expectations of the position without compromising patient care.