Mercy Health System Janesville , WI 53548
Posted 3 weeks ago
Overview
Patient Care Coordinator's primary responsibility is to oversee panel management for the primary care patients of the practice, to monitor chronic disease management and support providers in both. This includes both proactively working with patients to receive needed services, and to also assist patients within the clinic setting to meet their desired health goals.
Responsibilities
Essential Duties and Responsibilities
Actively case manages assigned panel of chronic care patients.
Oversees the prevention care reminder program for the practice's patients, ensuring that patients receive reminders of the need for preventive or disease management screening and testing.
Leads the physician care teams in ensuring a smooth transition of care for patients seen or treated in an ED, IC or as an inpatient.
Coordinates the process of determining the needs of various sets of individuals, including those identified chronic care conditions, using Epic and registry reporting to determine which patients are overdue for: care; services; or testing.
Develops a community resource list of services available to patients and maintains collegial relationships with community resources agencies used most frequently.
Contacts patients between visits via telephone, email or MyChart to check on self-monitoring, provide encouragement and support, and assess patient progress toward health status goals;
Participates in the process of incorporating evidenced based diagnosis and treatment guidelines into the management of patient panels.
Acts as a resource to assist the Clinic Partners with Medical Home patients who are non-compliant with their plan care.
Introduces new patients to their disease care plan in the Medical home.
Culture of Excellence Behavior Expectations
To perform the job successfully, an individual should demonstrate the following behavior expectations:
Quality
Service
Partnering
Cost
Education and Experience
Graduate of an accredited nursing program. BSN or upon hire BSN completion agreement for enrollment in an accredited BSN Completion Program May require specific years of applicable experience to qualify (per department guidelines). If hired prior to 1-1-14 in Winnebago County and prior to 9-1-14 in Rock, Walworth and McHenry Counties an ADN only is required.
Certification and Licensure
Licensed as an RN in the state of practice
Skills and Abilities
Excellent organizational skills
Computer skills
Self starter
Works independently with little or no supervision.
Spanish speaking preferred
May include color blind test (per department guidelines)
Special Physical Demands
While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee must occasionally lift and or move up to 10 pounds.
Level of Supervision
N/A
Supervises
N/A
Mercy Health System