Location: Main Street Medical Clinic, P.A.

Position: Care Coordinator - Quality Program Specialist

OVERVIEW: The primary responsibility of this position is to manage care for the patients of the primary care practice to promote effective patient education, self-management support, increased adherence to recommended preventive care, and timely health care delivery. This includes developing and monitoring care management processes and quality improvement workflows, and providing support to primary clinical teams with these efforts. It also includes identifying the high acuity patient population and working to ensure care management for this patient population.

RESPONSIBILITIES:

• Work with all clinical teams as a resource on care management of all patients of the practice
• Perform follow up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission
• Involve the patients in activities to improve their health and educate the patients about self-management tasks they can undertake to gain greater control of their health status
• Identify and effectively utilize community resources to meet the needs of patients/families
• Facilitate patient access to community resources as appropriate
• Promote patient self-management and empower patients/families to achieve maximum levels of wellness and independence
• Collaborate with the patient, physician, and other care team members in assessing the patient's progress toward individual health care goals, and assess barriers when patient has not met treatment goals, is not following treatment plan of care, or has not kept important appointments
• Participate in team meetings and departmental and organizational committees as applicable
• Demonstrate ability to work independently, while collaborating with other team members
• Develop, monitor, and refine workflows and processes with the goal to increase patient adherence to guideline concordant medical care
• Review utilization and quality reports routinely and scan for gaps in care to identify patients needing the additional support of care management
• Perform all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing
• Perform medication reconciliation for all care transitions
• Provide coverage across the organization as needed
• Work collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures
• Perform any additional tasks requested by Office Manager or Physicians

COMPETENCIES:

• Good organizational skills to handle multiple priorities while remaining professional and calm
• Ability to work with many diverse people
• Excellent written and oral communication skills
• Strong level of confidentiality due to the sensitivity of materials and information handled
• Must able to make suggestions on workflow or system efficiency and effectiveness
• Ability to work independently and be self-directed and flexible
• Ability to prioritize
• Ability to perform functions with minimal supervision
• Ability to work at a high-volume level of accuracy
• Ability to communicate effectively with providers and medical staff
• Computer skills proficient to expert
• Problem solving skills
• Proficiency in medication indications and side effects
• Understanding of medical tests and requirements for test as to provide the patients with appropriate information

QUALIFICATIONS:

• Active Arkansas Registered Nurse or Licensed Practical Nurse licensure required
• Relevant experience in care management or quality improvement programs preferred
• Minimum of three years of experience as a licensed nurse in a primary care setting preferred; experience in care coordination preferred
• Experience with eMDs Solution Series EHR software desirable

Please note this position is posted on behalf of our partner practices. This individual will be working at the specific practice that is mentioned in the above details and will not be a direct employee of Aledade, Inc. so will therefore not be eligible for the benefits available to Aledade employees.