Patient-Centered Medical Home RN Care Coordinator - PeeDee

Job Description Summary

The role of the Patient-Centered Medical Home (PCMH) Care Coordinator III is a nurse that works collaboratively with the physicians, staff and other health care professionals to actively facilitate health care delivery and promote care team communication for an assigned patient population ensuring appropriate care is provided.

This position will be remotely based, in the PeeDee area. This position will be required to round in clinics 1-2 days per month.

Entity

MUSC Health Partners (MHP)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC000101 CFC PC Patient Care Medical Home CC

Pay Rate Type

Hourly

Pay Grade

Health-27

Scheduled Weekly Hours

40

Work Shift

Job Description

Job Duties

•  Identifying patients that qualify for care coordination: not meeting clinical goals and quality measures (i.e. hypertension and diabetic control) for CCM pts, overdue for visits, labs, or referrals and arranging for follow-up services as appropriate for CCM pts, chronic care management (CCM), identify gaps in care and respond with appropriate action to correct. TCM coverage as needed.

• Utilizes Epic registries and reports in accordance with process (i.e. CCM-weekly & daily, quality measures) to identify patients and needs.

• Outreached to patients identified for care coordinator services (i.e. CCM, quality measures) & documents attempt (s) & completion.

• Scheduled services and places referrals in accordance with patient need (s) (i.e. vaccine, labs, appointment, mammogram, etc.)

• Follow up as appropriate to track data.

•  Accurately maintains 100% of data received.

•  Communicates effectively and professionally with patient (s), care team (s) and providers to provide support for continuity of care between patient, care team, and assigned providers

• Compiles and summarize information for quality measures and projects.

• Attend 80% of staff meetings.

• Maintains communication with providers & care team members (i.e. Epic inbox message, email, phone, office schedule, in person) Identify patient needs and/or barriers (psychosocial and other) to care and coordinate patients/families contact with community resources.

• Completes & documents accurate information gathering of data.

• Completes Epic & community referrals as needed.

• Communicates & follow up of identified barriers to the appropriate care team member/resource.   

• Other duties as assigned.

Additional Job Description

Education and Work Experience

• Minimum Associates Degree in Nursing

• Current South Carolina RN required with a minimum three years’ experience as an RN.   

• Computer skills to include proficiency in MS Word, Excel and PowerPoint. 

• Working knowledge of an electronic medical record application. 

• A team player that can follow processes to achieve a common goal. 

• Highly organized and well-developed oral and written communication skills. 

• Must be able to analyze and interpret data.

Degree of Supervision

Must be able to work independently under the supervision of the PCMH Clinical manager. Ability to work with Site Supervisors, Providers and others on the care team along with external stakeholder.

Licensures, Registrations, Certifications

Current license as an RN in the state of South Carolina. Updated BLS certification.

Physical Requirements

   Continuous requirements are to perform job functions while standing, walking and    sitting. Ability to bend at the waist, kneel, climb stairs, reach in all directions, fully use both hands and legs, possess good finger dexterity, perform repetitive motions with hands/wrists/elbows and shoulders, reach in all directions. Maintain 20/40 vision     corrected, see and recognize objects close at hand and at a distance, work in a latex safe environment and work indoors. Frequently lift, lower, push and pull and/or carry objects weighing 50 lbs (+/-) unassisted, exert up to 50 lbs of force, lift from 36” to overhead 25 lbs. Infrequently work in dusty areas and confined/cramped spaces. Ability/willingness to travel frequently to MUSCP-PC clinical locations away from the main campus.

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees