Lone Star Circle of Care

  • Population Health: Nurse Care Coordinator

    Job Locations US-TX-Georgetown
    Posted Date 2 weeks ago(6/5/2018 6:00 PM)
    # of Openings
    Nursing (LVN/RN)
  • Overview

    The Population Health team at LSCC manages organizational performance on clinical metrics, patient engagement, and cost containment for value-based contracts. Nurses on this team work in a central hub, remotely assisting clinic-based team members in managing panels of patients and closing any gaps in metric performance. As such, they are involved in report analysis, medical record review and abstraction, patient outreach and appointment scheduling. Indirect patient care is provided via telephonic and/or other electronic communications, and effectively engaging patients is an important part of this role.


    Nurse Care Coordinators on the Population Health team are expected to work closely with the Chief Medical Information Officer and the Analytics team to develop reports that measure organizational performance against contracted metrics. Nurses must be able to skillfully dissect data reports to identify areas of concern and take ownership for the organizational improvement, maximizing the likelihood of the organization earning contracted incentives. When risks are identified, the nurses work as a team, collaborating with medical and executive staff, to develop a performance improvement plan. The Population Health team then continually measures results against that plan, communicating progress with the executive team, and correcting course when necessary.


    Staff perform duties under the direction of the Chief Medical Information Officer, assisted by an RN Manager, to serve as patient advocates, providing remote-based care, system navigation, and education. This position provides direction to Licensed Vocational Nurses (LVNs) and Medical Assistants (MAs) as well as other non-licensed nursing personnel in the provision of patient care.




    Daily Job Duties:


    • Obtain, evaluate, and record information in patient record
    • Perform outreach to patients as directed using telephonic and/or other communication modes (text, email, mail). Use navigation center web-based call platform when placing outbound calls.
    • Perform and ensure proper documentation of patient communications and clinical treatment accurately in the use of the Electronic Health Record (EHR) system
    • Serve as an advocate for health, educating patients about wellness, routine preventive care, and screenings. Explain recommended tests and treatments. Encourage patient engagement with the Population Health team.
    • Perform patient screenings (e.g., socioeconomic barriers to care, depression screening, tobacco use screening) electronically, and based on screening results, assist patients in obtaining any necessary social services or medical care
    • Efficiently use care coordination reports to identify care gaps and work with leadership to develop a plan for closing that gap through medical record abstraction, patient outreach, and collaboration with patient-facing colleagues in the clinics.
    • Use risk stratification algorithms to identify the highest risk patients. Develop strategies for intensive interventions designed to decrease the risk of poor health outcomes for that population.
    • Use data to identify patients with a high rate of inappropriate utilization of healthcare resources, such as non-urgent Emergency Department visits, and perform outreach designed to educate patients about appropriate utilization, uncover socioeconomic factors contributing to that utilization, and help develop strategies to address those factors.
    • Professionally collaborate with LSCC healthcare providers to provide optimal care for our patients through electronic communication (bidirectional tasking in the EHR; recording your outreach work in the EHR’s care coordination template)
    • Communicate with external healthcare organizations to obtain the status of patient appointments or referrals and to advocate on the behalf of our patients in receiving necessary healthcare
    • Develop collaborative working relationships with other members of the care team who are based in the clinics, including nurses, site managers, and service line directors
    • Engage patients with the Population Health team by serving as their advocate in willingly assisting in healthcare system navigation, in inquiring about barriers (cost, transportation), and providing solutions to overcome those barriers to receiving care
    • Assist with clinical tasks (performed centrally, at the navigation center, not in clinics) as assigned. May include, but not limited to, responding to task requests from providers, completing prior authorizations, processing referrals, handling medication refills, and communicating lab or diagnostic results to patients.

      Utilize the Population Health team’s electronic ticketing system to track daily and weekly task assignments and mark completed tasks as done.

    • Participate in all trainings and refreshers as appropriate.
    • Participate and collaborate in team meetings.

    • All other duties as assigned


    Compliance/Customer Service/Training:


    • Maintain patient care standards following established LSCC health education and information guidelines
    • Participate in focus groups, and quality improvement initiatives
    • Organize work and utilize time efficiently based on knowledge and procedures
    • Assume responsibility for his/her own professional development and for sharing knowledge with others
    • Invest own time and effort to improve knowledge, skills and judgment
    • Responsible for knowledge and compliance of all LSCC policies and procedures
    • Maintain professional manner and appearance



    • Staff Members and Directors shall deal with patients, providers, colleagues, and other internal and external LSCC contacts honestly, professionally and with empathy, following the principles of AIDET (Skill at a Glance) and the Language of Caring Overview (Staff). Staff Members and Directors shall demonstrate honesty and integrity in all LSCC business activities and work scheduling
    • Following the principles of AIDET and Language of Caring, Staff Members and Directors are expected to treat one another with respect and courtesy, understanding that each Staff Member and Director has special talents and capabilities necessary to fulfill LSCC’s Mission, Vision, and Values.
      • Principles of AIDET (Acknowledge, Introduction, Duration, Explanation and Thank You) at all times with patients, colleagues, visitors and leadership
    • The Language of Caring skills are versatile life skills that enhance communication and strengthen relationships that apply to all of us, whether we serve patients and families directly, or we serve the people who do—our internal customers.






    • Graduate of an accredited vocational nursing school
    • BLS certification from American Heart Association (AHA)
    • Valid State of Texas Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license; salary commensurate with experience
    • Minimum of three (3) years of work in the healthcare field



    • Previous nursing experience in a Clinic/Outpatient environment
    • Previous work using Electronic Health Records (EMR)
    • Bilingual English/Spanish language skills are a definite plus
    • Proficiency with MS Office Suite (Word, Excel, and Outlook)


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