Department or Business Unit: Population Health
Reporting Structure: AVP, Population Health GC
Employment Type: FTE
Exemption Status: Exempt
Min. Experience: Mid-level
Travel Required: Yes
Overview of the Role:
The RN Nurse Coordinator works closely with the population health team, networked facility partners, primary care providers, and practice operations to ensure seamless transitions in patient care. The RN Nurse Coordinator will provide extensive care coordination for Privia’s highest risk patients, assist in closing quality gaps, and patient outreach to educate on medication adherence.
Primary Job Duties:
- Under the direction of the AVP Population Health, in collaboration with the Associate Director of Quality Manager and Population Health Coordinators to achieve Quality targets
- Manage a robust patient case load
- Develop specific care plans for Aligned Value-Based Care Program (VBC) Participants who are in the top 5% of highest risk patients. The care plan should include diagnosis- specific recommendations, medications, follow-up appointments, and sick day plans to prompt a call to the Provider.
- Coordinate care for Aligned VBC Program Participants that are high risk/high utilizer patients.
- Proactive patient communication and coordination of care between visits.
- Develop trust and build rapport with a select (high-risk/high utilizer) Privia patient population
- Establish “call me first” relationship with your patients
- Perform patient transitions of care. Post-hospitalization outreach may include follow-up office visits, medication reconciliation, creation of a sick day plan, teaching and coaching regarding the need for follow-up care, and other interventions as medically appropriate.
- Document patient engagement conversations with all Aligned VBC Program Participants, including those who have been hospitalized or have had an emergency room visit, and those for whom an ECC is coordinating care due to COVID-19 high risk, or other high risk or chronic conditions.
- Utilization of CPTII Codes
- Referral to and coordination with patient’s payer case management and disease management programs available to Participants, consultation with payers on specific issues related to evidence- based quality guidelines, gaps in care, overall care plans, and coordination of patient care and communication for specific Aligned VBC Program Participants.
- Act as the liaison and advocate between the PCP and patient to address Medication Adherence
- Engage patients telephonically, in office, in facility, or where needed
- Act as the liaison and advocate between the PCP and patient, as well as with payer partner resources when appropriate/available
- Assist patients in accessing care at the appropriate source
- Have attention to detail for patients: medical, behavioral, social, and economic issues - work to mitigate these barriers
- Review patient non-compliance issues related to open gaps and conduct outreach to attempt to close them
- Schedule patients for diagnostic testing and follow up to ensure completion of testing
- Develop relationships with the care coordination teams
- Participate in special projects and perform other duties as assigned
- Evaluate and utilize data from EMR to support patients’ needs
- Maintain a courteous and helpful manner when working with patients, physicians, care center staff, Privia partners, and payers.
- BS in Nursing (or equivalent) and at least 3 years of case management or care coordination experience.
- Medicare Advantage and ACO experience preferred
- Ambulatory Care Management, Home Health, or Long-Term Care experience preferred; Experience with triage preferred
- Active unrestricted license in TX or able to obtain
- Must comply with HIPAA rules and regulations
Interpersonal Skills & Attributes:
- Effectively communicates with physicians, care center office staff and patients
- Demonstrate sound judgment/critical thinking skills
- Maintain a positive caring attitude towards patients
- Strong computer and EHR skills and expertise
- Must be detail oriented and possess varied analytical skills
- Possess a focused work ethic and a high level of professionalism
- Flexible, as travel may be required
- Microsoft Office and Google skills
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk and hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.