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.
- 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.
- 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.
Job Type: Full-time
- Bachelor of Science in Nursing (BSN) (Preferred)