CRMG - Care Coordinator (Elizabeth City, NC)

CRMG - Care Coordinator (Elizabeth City, NC)

Job Category: Operational Professional

Full-Time

Hybrid

Elizabeth City, NC 27909, USA

Job Details

Description

Essential Duties and Responsibilities

• Provide annual wellness visits for identified patients.
• Perform outreach to patients and schedule annual wellness visits.
• Assess patients' health status, identify risk factors, and develop personalized care plans based on findings.
• Conduct non-invasive assessments and screenings, review medical history, ensure accurate documentation, and perform medication reconciliation to enhance patient safety and compliance.
• Develop and update personalized prevention plans with patients based on their current health and risk factors.
• Provide basic patient education on wellness and preventive healthcare measures, including healthy lifestyle choices, screenings, vaccinations, and disease management.
• Collaborate with primary care providers to identify health gaps and review findings from annual wellness visits.
• Understand and utilize available reports to identify high-risk patients.
• Assist patients in navigating the healthcare system by serving as a patient advocate.
• Educate patients and caregivers on disease management and prevention.
• Coordinate continuity of care with external healthcare organizations and specialty providers, including hospitals.
• Coordinate patient and family follow-up care after hospital admissions, discharges, and emergency room visits.
• Manage care for high-risk patients, including those with multiple comorbidities or at high risk for hospital readmission.
• Collect and report data pertinent to clinical audits and program evaluation related to the Patient-Centered Medical Home and other population health initiatives.
• Develop and implement processes and pathways for population health management.
• Compile data from multiple sources to support total patient care.
• Attend required hospital-wide orientations, meetings, and in-services.
• Demonstrate flexibility in work scheduling when necessary to ensure patient care coverage.

Education and Experience

Minimum Required Education: LPN

Experience: Primary care experience preferred, with demonstrated proficiency in assessing and managing patients with complex health conditions and multiple co-morbidities. Prior Patient-Centered Medical Home experience preferred. Experience with electronic medical records and data reporting required.

Certificates, Licenses, and Registrations

• Current LPN or RN licensure in Virginia or North Carolina
• CPR: BLS certification

Qualifications

Education

Preferred: Bachelors or better in Nursing.

Experience

Preferred: Primary care experience

Licenses & Certifications

Required: Basic Life Saving, Cardiopulmonary Resuscitation, Licensed Practical Nurse

Preferred: Registered Nurse

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.