WI3663710

1

Unspecified

40

JOB REQUIREMENTS: Pillar Health is looking for experienced Registered
Nurse Care Coordinators. \$5,000 hiring bonus - See below for details.
POSITION SUMMARY The Registered Nurse Care Coordinator (RNCC) has a
vital role within the KCHC/Pillar Health integrated care model. As a key
partner to an assigned care provider(s) they support management of a
patient panel using proactive and planned care goals while also
coordinating the care team necessary to achieve them. The RNCC
participates in the delivery of evidence-based care to an assigned
patient population utilizing defined care standards, identifying care
gaps, ensuring efficient access to care, care planning, and facilitating
seamless care transitions and care continuity. The RNCC also
participates in the analysis of outcomes, identification of
opportunities for improvement, and implementation of changes to optimize
outcomes for individual patients and the overall population. The
position of the RNCC in the care model places the role in a unique
position to facilitate an inter-professional team of clinicians in a
wraparound care coordination model that will identify and address
patient emergent, chronic, preventative care and social needs placing
place patients in the best position for optimal health outcomes.
ESSENTIAL FUNCTIONS The list of duties and responsibilities is not all
inclusive and may be expanded to include other duties and
responsibilities, as management may deem necessary from time to time.
Coordination and Management of the Patient Panel \* Reviews and assesses
patient registration data, including outpatient or inpatient treatments,
emergency room visits, medications, chart reviews, to assist in the
monitoring and facilitation of adherence to prescribed care plans. \*
Using the Electronic Health Record (EHR) and other electronic resources
to identify patient care gaps and coordinate activities with the
provider and care team to close those gaps. \* Utilizes organization
defined risk stratification tools, EHR, and other electronic resources
to risk stratify the assigned patient panel and track indicators of the
panel. \* Chronic Care Management of medium, rising risk and high-risk
patients \* Draw conclusions from available data to develop an overall
strategy for the assigned patient panel as a whole, and individual
patients in the different risk groups. \* Routinely evaluates social
needs that can negatively impact health outcomes. Connects patients to
available resources to meet those needs. \* Initiates or contributes to
the development and implementation of individualized, comprehensive care
plans including medical and social needs. \* Accesses internal and
external resources to support development and implementation of\... For
full info follow application link. Kenosha Community Health Center is an
Equal Opportunity employer. All qualified applicants will receive
consideration for employment without regard to race, color, religion,
sex, national origin, disability or veteran status. \*\*\*\*\*
APPLICATION INSTRUCTIONS: Apply Online: ipc.us/t/A4BAAF874E0546D5