Advanced Care Management Coordinator, RN

Join a dedicated healthcare team in the Midwest region as an Advanced Care Management Coordinator. This role focuses on delivering comprehensive care coordination to ensure patients receive timely, high-quality, and efficient healthcare and support services both within and beyond the medical home. You will develop and implement personalized care plans while empowering patients with self-management skills.

Key Responsibilities

• Assist with social services and address social determinants of health, including advanced directives, transportation, financial aid, mental health resources, medication support, food pantries, shelters, utility assistance, housing, mandated reporting, and health education.
• Provide guidance and support for Medicaid, disability, financial assistance, and government aid applications.
• Ensure timely processing of referrals and proactively resolve barriers affecting patient care continuity.
• Collaborate with social workers and care managers to facilitate smooth transitions post-hospital discharge.
• Educate patients and caregivers on self-management and patient portal benefits, assisting with setup during service visits.

Education

Graduation from an accredited School of Nursing, Social Work, or a related field is required.

Experience

A minimum of two years in a healthcare setting is necessary, with case management experience preferred.

Certifications and Licenses

Possession of a Missouri or Compact RN license is required if applicable. Case Management certification is preferred.

Physical and Mental Requirements

This position demands considerable mental focus for extended periods, often with interruptions. Physical activities include standing, walking, sitting, and light lifting up to 15 pounds.

Working Environment

Expect exposure to body fluids and frequent interaction with community agencies, patients, providers, vendors, families, and staff. The setting is a typical medical clinic and hospital environment with noise and distractions, including potential eye strain from computer use.