Care Coordinator CRMG

##### **Summary** ##### To coordinate and perform Medicare Wellness visits, in collaboration with health care teams to ensure the highest level of service is provided. To ensure that CRMG practices are fulfilling the responsibilities of population health management within the practice setting. ##### **Essential Duties and Responsibilities** ##### These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned. * ##### Provides annual wellness visits for identified patients. * ##### Perform outreach to patients, schedule patients' annual wellness visits. * ##### Assess patients' health status, identify risk factors, and develop personalized care plan based on the findings. * ##### Perform non-invasive assessments, screenings, review medical history, ensure accurate documentation, and conduct medication reconciliation to enhance patient safety and compliance. * ##### Develop and update a personalized prevention plan with patients based on their current health and risk factors. * ##### Provide basic patient education on wellness and preventative healthcare measures, including information about healthy lifestyle choices, screenings, vaccinations, and disease management. * ##### Collaboration with primary care providers identifying any health caps, and findings during the annual wellness visit. * ##### Understanding and utilizing reports available to identify high risk patients. * ##### Assisting patients through the healthcare system by acting as a patient advocate. * ##### Educates patients and caregivers on disease management and prevention. * ##### Coordinates continuity of patient care with external healthcare organizations and facilities including hospitals and specialty care providers. * ##### Coordinates continuity of patient care with patients and families following hospital admissions, discharges and ER visits. * ##### Manages high risk patient care, including management of patients with multiple co-morbidities or who are at high risk for readmission to a hospital setting. * ##### Collects and reports data that is pertinent to clinical audits and programmatic evaluation related to Patient Centered Medical Home and other population health initiatives. * ##### Develops and implements processes and pathways for population health management. * ##### Able to compile data from numerous resources to achieve total patient care. * ##### Attend required hospital-wide orientations, meetings, and in-services. * ##### Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care. ##### **Supervisory Responsibilities** * ##### **Reports to:** Director CRMG * ##### **Supervises:** NA * ##### **Responsibilities:** Annual Wellness Visits ##### **Qualifications** ##### To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The 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** * ##### **Minimum Required Education:** LPN * ##### **Experience:** Primary care experience, proficiency in assessing and managing patients with complex health conditions and multiple co-morbidities. Prior experience with Patient Centered Medical Home experience preferred. Experience with electronic medical records and reporting required ##### **Certificates, Licenses, Registrations** ##### LPN or RN licensure in Virginia or North Carolina CPR: BLS certification