CRMG - Care Coordinator (Elizabeth City, NC)

**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