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Population Healthcare Management RN Clinic C3 - Clinic
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- The Concierge Care Coordination Nurse at the clinic complements the practitioner-patient relationship through support of the established plan of care, using cost-effective, recommended practice guidelines.
- Job functions are performed in accordance with requirements of the Medicaid contract, Community Care Plan (CCP) Health Services policies and procedures, and Patient Centered Medical Home (PCMH) standards.
- Analyze clinical information to identify members and to determine eligibility and appropriateness for enrollment in the Concierge Care Coordination Program.
- Assess hospitalized enrollees for the need for ongoing care coordination, disease management or open gaps in care, working with hospital and providers to meet enrollee needs.
- Conduct outreach and follow-up on any enrollee with a pattern of emergency room visits to assess for contributing factors and develop actions to reduce avoidable emergency room and potentially avoidable hospital admissions.
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