Patient Care Coordinator – Clinical Nurse – Social Worker
As a member of the VBC program team, the Patient Care Coordinator/Social Worker is an advocate for the patient, collaborates with physician offices, and clinical team to meet the patient care initiatives and ACO metrics. One of the most important roles is to ensure compassionate, effective, and efficient delivery of high-quality care coordination. The continuum of care includes inpatient to outpatient to community and covers Pediatric, Adolescent, Adult and Geriatric.
Essential Duties and Responsibilities:
- Coordinate care with the physician office to ensure identified preventive care needs are met, provide case management, identify community and social services.
- Daily review of patient admits and discharges to determine and assist with transition of care activities.
- Provides in timely manner accurate and pertinent patient information to assist in patient care discussions with the Clinical Leadership.
- Utilize Electronic Health Record (EHR) to identify care gaps for preventative care, chronic care, specific medications, high risk patients and those not seen recently in primary care practice.
- Fosters ongoing and active interaction with all physicians, payors and community groups as assigned.
- Demonstrates understanding and compliance with all Value Based Care (VBC) program specific quality metrics and what is required to successfully close the metric.
- Work independently and collaborates as needed with Clinical Leadership, Medical Director, and/or non-clinical partners.
- Ability to work in the internal and external (multiple payor systems) and document updates effectively.
- Ability to adapt to a highly changing environment.
- Assist leaders and/or other team members as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The education, experience and requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and Experience Required
- Current, valid Texas RN, LVN or Social Worker State License in good standing.
- One – two plus years’ experience.
- Maintain confidentiality and complete annual HIPAA training.
- Must have basic skills with care management software platforms, various electronic medical record systems, Microsoft office, and similar types of systems for documentation and reporting.
- Ability to work a full-time (40 hours minimum) flexible work schedule.
- On occasion will require travel to provider offices during work hours.
Knowledge and Skills
- Ability to interact with an interdisciplinary care team (patients, senior leaders, partners, and providers).
- Demonstrate the ability to work effectively in a team environment.
- Demonstrate problem solving skills in an ever-changing environment.
- Demonstrate effective interpersonal relationship and customer service skills.
- Effectively manage time and meet role expectations.
- Ability to work effectively with people from diverse cultures.
- General office demands.
- Full-time position
- Salary with eligible annual bonus
- Work location: On site 60% and Remotely 40%.
As a PPN employee you’ll enjoy benefits including 401(K) with a 3% match, four (4) weeks paid time off in addition to company holidays, employer paid health insurance for the employee with excellent choices including HSA and HRA options, and six (6) weeks paid family leave after one (1) year of service.
We are proud to be an EEO employer. We maintain a drug-free workplace. Additional information on PPN may be found at http://www.ppnhco.com.