Nurse Care Coordinator, RN

Loudoun Medical Group - Leesburg, VA (30+ days ago)2.8


Loudoun Medical Group (LMG), one of the largest and most diverse physician-owned, multi-specialty group practices in Virginia, seeks an experienced, Nurse Care Coordinator to assist providers with coordination of care management and community services for high-risk patients in an outpatient setting.

Summary of Position:
The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high risk” patients and their family/caregiver(s), providers, and specialist in a team approach to:

  • Promote timely access to appropriate care
  • Increase utilization of preventative care
  • Reduce emergency room utilization and hospital readmissions
  • Create and promote adherence to a care plan
  • Increase continuity of care by managing relationships with providers, transitions in care, and referrals
  • Work to increase patients ability for self-management and shared decision-making
  • Provide medication reconciliation
  • Connect patients to relevant community resources to enhance patient health and well-being, increase patient satisfaction, and reduce health care costs.

Responsibilities :

  • Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
  • Coordinates the care of high-risk targeted population in an efficient, cost-effective manner to plan and monitor care:
  • Assess patient’s uncontrolled chronic conditions and social needs
  • Develop a care plan with the patient, family/caregiver(s) and providers.
  • Monitor adherence to care plan, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.
  • Identify and refer patients to eligible programs.
  • Facilitate and attend meetings between patient, family/caregiver(s), providers, care team, and payers as needed.
  • Communicate and collaborate with providers in supporting implementation of patient care plans and management of the patient with timely communication, inquiry, follow-up, and integration of information.
  • Establishes and maintains a professional, collaborative relationship with the patient, family, and providers to assess the options for care and use of benefits and community resources.
  • Analyze payer reports to identify “high-risk”, “high medical utilization” patients, and follow established work flows to address findings.

Requirements :

  • Licensed RN in the state of Virginia
  • A minimum of 3-5 years’- of experience in a busy clinical setting.
  • Highly organized with ability to keep accurate notes, records, and documents proficiently.
  • Ability to communicate and elicit patient medical information both verbally and written, to include contacting patients telephonically, documenting nurses notes in EMR, and collaborating with providers and care team.
  • Computer skills (must be extremely proficient with Microsoft, specifically Excel spreadsheets)
  • Experience using Electronic Medical Records systems i.e. Pulse, eClinicalworks, Allscripts, etc.
  • Ability to critically think and identify patient needs and barriers to care.
  • Ability to collaborate with primary care physicians and allied health professionals for successful program outcomes
  • Demonstrates commitment to ongoing education preferred
  • Experience working with high-risk patients preferred
  • Care coordination or case management experience is strongly preferred
  • Local knowledge about and connections to community health care and social welfare resources is desirable.
  • Full-time hours 8:30am – 4:30pm (Monday through Friday) with occasional evenings (if needed).
  • Reliable source of transportation with ability to travel to and from the hospital and LMG physician offices.

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Job Type: Full-time

Education:

  • Bachelor's (Required)

Work authorization:

  • United States (Required)

Nursing Degree:

  • Bachelor of Science in Nursing (BSN) (Preferred)