Up To $25,000 Sign On Bonus For Qualified RNs! Position Summary Care Coordinator will serve as the clinical support for case management and disease management for Guthrie Network Advantage Medical Plan members. The Care Coordinator has the responsibility and accountability for coordinating the medical management of patients, using an outcome-based approach. In collaboration with other members of the healthcare team, the Care Coordinator identifies at risk patients, develops a plan of care, and coordinates care with the patient’s involvement. Will work with physicians and other members of the healthcare team as he/she supports the quality process and performance objectives through data collection and data analysis. Individual will work with the Human Resource staff responsible for oversight of the health plan data (Human Resources) and with the health plan third party administrator/pharmacy benefit manager on the member’s care. Experience A minimum of five (5) years relevant clinical experience who demonstrates leadership and autonomy in nursing practice. Preferred experience with care management/utilization review, and payer knowledge. Fast paced ambulatory care experience preferred. Education Bachelor’s degree in nursing or related field required. With an employment agreement, will consider an applicant who is actively pursuing their bachelor’s degree. Master’s Degree preferred. Licenses The Care Coordinator must be licensed in both New York and Pennsylvania. The applicant must have a current license as a Professional Registered Nurse in their state of practice prior to the position’s start date. Additional state licensure must be obtained within 6 months of hire. Patient outreach and contact will be limited to those patients living in the state of current licensure until dual licensure is obtained. Essential Functions 1. Supports the Care Management (CM) and Disease Management (DM) of Health Plan members. a. Identifies patients for case management/disease management through EPIC registry reports, provider referrals, and health plan third party administrator/pharmacy benefit manager reporting. b. Using EPIC Disease Registry reporting and Payor reporting, identifies patients who have gaps in care as they relate to chronic disease states and disease prevention. c. Provides patient education and material on the appropriate management of chronic medical conditions, using evidence-based guidelines of care. d. Supports patients through care transitions. e. Actively participates in Human Resource meetings as they relate to Case Management and Disease Management f. Prepares and provides monthly reporting as it relates to CM and DM. 2. Supports Population based initiatives in Health Plan members. a. In cooperation with Human Resources, identifies population-based initiatives for the prevention of disease and improvement of health (eg. Smoking cessation, preventive screening exams, routine immunizations) b. Meets with Health Plan members individually and in group settings to support such initiatives. c. Prepares and provides monthly reporting as it relates to population-based initiatives. 3. Supports Human Resources in providing updates to care received, continued care, etc. for health plan members in forecasting future needs. a. Regular meeting attendance with third party administrator/pharmacy benefit manager. b. Support the primary care practice with the use of technology, including Microsoft and EPIC Software. Functionality would include reporting Workbench, Patient Outreach (eGuthrie, Health Maintenance, Care Everywhere, EPIC Care Link) and Disease registry tools. c. Works directly with third party administrator/pharmacy benefit manager on patient care issues. Management and reporting of data from third party administrator/pharmacy benefit manager. a. Ambulatory Care Management Team Member a. Collaborates with Primary Care Office Care Coordination staff b. Participates in Care Team meetings. c. Participates in Staff meetings. Other Duties 1. Travel for this position may be required. 2. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures. 3. It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position. Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community. The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace. The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.