RN Care Coordinator

Medical · Mankato, Minnesota
Department Medical
Employment Type Full-Time
Minimum Experience Experienced

Job Summary:

The RN Care Coordinator is responsible for providing culturally, linguistically and age appropriate coordinated patient centered care across the health care continuum. S/he works in collaboration with an interdisciplinary team to provide comprehensive care coordination services to patients, including provision of appropriate services in multiple care settings. The RN Care Coordinator works to optimize the health and wellness of each patient, actively engaging the patient/family in prevention, promotion and management of health problems to achieve quality outcomes.  


Job Responsibilities

  • Promotes patient engagement in healthcare and provides opportunities for education, intervention and patient advocate and empowers patients to engage in self-advocacy.
  • Serves as contact point and informational resource for patient’s care team, family/caregiver(s), payers, and community resources
    • Analyzes patient record to determine utilization patterns and opportunities for intervention.
    • Initiates patient contact and creates ongoing processes for continued communication and plan of care.
    • Conducts monthly telephone or face to face assessment of patient needs and risk factors.
    • Utilizes electronic patient registries, EHR, Dentrix and other self-monitoring clinical tracking tools to monitor treatment compliance, engagement in care, and other population-specific disease outcomes for patients living with chronic illnesses.
    • Must be able to readily compile clinic-specific data and report to Leadership as requested.
  • Assist patient in facilitation of needs.
    • Works with the patient and family to develop an individualized plan of care.
    • Tracks and facilitates scheduling of appointments.
    • Facilitates access to providers, services and resources using cost effective practices.
    • Develops and maintains evidence-based patient education resources to provide to patients in the clinic, via the EHR or through the patient portal.
    • Provides for education and counseling on health promotion, illness prevention strategies and contingency plans.
    • Monitors and adjusts the care plan in the EHR based on patient progress and any changes in condition or environment.
    • Provides mentoring/coaching of other population health and care coordination team members and coach patients/families toward successful self-management of their chronic disease.
  • Support collaborative care between primary care, specialists and other health care agencies with timely communication and integration of information to ensure continuity and follow-up.
    • Communicate and document on patient status and needs with primary and specialty providers.
    • Collaborate with all health care providers to develop an integrated treatment plan.
    • Obtain reports and other necessary documents for the provider to provide patient care in a safe, caring environment.
    • Manage transitions between outpatient and acute care settings; initiate referrals as needed.
    • Ensure messages taken for providers and medical staff are accurate.
    • Assist support staff with patient inquiries directly or indirectly utilizing phone, patient portal and EHR system.
  • Collaborate with other members of the health care team to improve quality and efficiency.
    • Participate in evaluation of patient outcomes, quality of care and utilization of services.
    • Assist in measuring, monitoring, improving/sustaining patient outcomes.
    • Attend meetings as needed or request with the Healthcare QI Analyst and Medical Services Manager.
    • Share accountability for achieving high quality patient outcomes related to clinical status and patient experience.
    • Assumes personal responsibility to remain informed of current evidence, trends and issues around chronic illnesses that impact our patient populations and UDS reporting measures.
  • Perform required nursing skills as needed for department.
  • Assist in preparation of patient care areas, including lab, and in the patient admission, transfer, referral and discharge process as required.
  • Follow clinic policies and procedures for infection control and in the handling and disposing of infectious/hazardous waste materials.
  • Maintain inventory of supplies in exam rooms and other areas as designated by Medical Services Manager; i.e. immunizations.
  • Work with Medical Services Manager to ensure effective and efficient daily operations.
  • Maintain necessary licensure and CPR certification as required by Minnesota state law and ODHC policy.
  • Keep the department Manager updated with any changes, concerns or issues regarding patients, programs, daily operations, outreach events, equipment needs, etc.
  • If bilingual, accurately and professionally interpret conversations.
    • If not bilingual, use appropriate and approved communication tool as needed.
  • Develop and maintain relationships with other ODHC staff to ensure efficient daily operations of all departments.
  • Be knowledgeable of ODHC services to provide integrated care to assist patients/families in accessing needed resources.
  • Know, understand, and ensure adherence to the organization’s policy related to the patients’ right for confidential care and HIPAA.
  • Keep updated on ODHC current events, changes in the workplace, policies and procedures.
  • Read email, Intranet, and other communication tools on a regular schedule and respond in a timely manner to requests, where applicable.
  • Perform other tasks as assigned.


Knowledge, Skills, Abilities, Qualifications:

  • Graduation certificate from an accredited RN school of nursing program, along with a current state license.
  • Experience in a family practice or ambulatory care setting to include education, direct patient care and triage.
  • Education and/or experience in the areas of community or public health a plus.
  • Proven technical competency in Microsoft Office products, Electronic Health Record (EHR) and Electronic Dental Record (Dentrix).
  • Experience working with a diverse population of people.
  • Strong interpersonal skills.
  • Exceptional verbal and written communication skills.
  • Excellent time management and organizational skills.
  • Ability to work independently or in a team environment.
  • Confidence, professional judgement and grace under pressure.

Cultural competency and bi-lingual skills are a must.

Thank You

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  • Location
    Mankato, Minnesota
  • Department
  • Employment Type
  • Minimum Experience