Care Coordinator - RN (New Orleans Market)

US-LA-Peoples Health- New Orleans
Job ID


Position Purpose

The Care Coordinator-RN (CCRN), as a part of the primary care patient centered medical home team, engages in a collaborative process, which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a member's health needs through communication and available resources to promote quality, cost effective outcomes. This process will be applied in various settings to include acute care, skilled nursing care settings, long term acute care settings, rehab facilities, custodial care, in ambulatory settings and in member's home. The CCRN functions as a member of a multidisciplinary team, which includes a Navigator, Care Coordinator-Social Worker (CCSW), Pharmacist and Nurse Practitioner.


Scope of Position                                                                                                                                                                                                                                                                                                                      The CCRN reports to the Clinical Director, Non-SNP Care Coordination, and is responsible for the management of an assigned population of members as part of the patient centered medical home model. The CCRN will also have responsibilities to maintain and ensure alignment with the mission of Peoples Health as outlined in the Mission Statement.



Principal Responsibilities

As part of a multidisciplinary care coordination team, the principal responsibilities are:

  1. Addresses the total individual, inclusive of medical, psychosocial, behavioral, cultural, and/or spiritual needs.
  2. As appropriate, conducts comprehensive assessment of the member's health and psychosocial needs, including health literacy status and deficits.
  3. Determines if the member is appropriate complex case management.
  4. Involves the individual member, and care giver as appropriate, in decision making.
  5. Collaborates in efforts that focus upon moving the individual to self-care when possible.
  6. Applies focus on points of care transitions, which includes a complete transfer to the next care setting provider that is effective, safe, timely and complete.
  7. Provides prompt, courteous, excellent service to internal and external customers at all times.
  8. Facilities communication and coordination between all members of the health care team.
  9. Interacts with the member and the multidisciplinary team to establish measurable health care goals and prioritization of the member's needs. Monitors the member's adherence to the plan of care. Identifies barriers to adherence to the plan of care.
  10. Educates the member, the facility or caregiver, about disease stats and treatment, plan benefits, community resources, and resource options. Evaluates the member's readiness and ability to learn.
  11. Encourages the appropriate use of health care resources.
  12. Collaborates with care team members and medical directors to facilitate appropriate treatment for members
  13. Participates in regional team meetings to improve member's outcomes and Peoples Health processes.

  14. Review daily facility census for assigned population.
  15. Coordinate discharge planning with facility case management and other care team staff for assigned members in all care settings.
  16. Documents appropriately in the Peoples Health CCMS system.
  17. Identify, plan and document all follow up to hospital treatment with the interdisciplinary team and primary care physician (PCP).
  18. Participate in meetings with the PCP for review of the census as indicated.
  19. Communicate discharge information to the Navigator in PCP office.
  20. Coordinator with the Navigator in the PCP office to facilitate the post hospital discharge visit within seven (7) days.
  21. During business hours, answers pages and phone calls received from hospital utilization review regarding the member's condition.
  22. Develops referrals to appropriate resources to assist member and/or care giver in continuation of care in an outpatient setting.
  23. If necessary, coordinates with member and/or care given to identify potential barriers from discharge to an alternate level of care.
  24. Participates with the interdisciplinary care team in review of assigned members.
  25. Promotes quality outcomes and participates in the measurements and understanding of the outcomes.
  26. Monitors performance against assigned member's gaps in HEDIS and Star measures through weekly report analysis.
  27. Utilizes evidence-based guidelines, as available, in their daily practice.
  28. Promotes a professional, positive image of Peoples Health throughout the community. Identifies and communicates community and Peoples Health departmental concerns to the appropriate department.
  29. Pursues professional excellence and maintains competence in practice through ongoing learning and continuing education.

Peoples Health Competencies

Every employee is expected to meet Peoples Health minimum requirements:

  • Commitment: to our Members: We have the power to change our members lives by placing them at the center of everything we do, everyday.
  • Action: By working together and delivering quality service, we enhance the lives of our members through dedication and teamwork.
  • Responsibility: To continue to strive to be the best for our members by adapting and evolving to change, continuing professional development, and to never stop learning.
  • Excellence: By exceeding expectations and finding innovative ways to exceed standards, we are changing our members' lives.


Additional Competencies

  • Professionalism
  • Communication skills (written and oral)
  • Planning and organizational skills
  • Creative, innovative and strategic thinker
  • Negotiation; conflict management and resolution skills
  • Manages time appropriately, efficiently, and effectively
  • Collaborates and is a team worker
  • Excellent interpersonal relations
  • Effective listener
  • Ability to effectively interact with multifaceted medical and professional staff.
  • Maintains pleasant and helpful attitude.




  • Diploma or degree in nursing
  • 3-5 years' experience in clinical or similar setting
  • Experience with clinical documentation systems
  • Experience in assessing members and developing care plans
  • Strong organizational skills, attention to detail, verbal and written communication skills



  • Bachelors in Nursing
  • Peoples Health employee for one (1) year
  • 1-3 years supervisory experience
  • Experienced in management care industry
  • Understanding of HMO and third-party administration
  • Understanding of nursing home and long term acute care regulations preferred.
  • Continuing education in the healthcare/managed care industry
  • Ability to operate standard office equipment, computer, printer, fax and copier.


  • Current Louisiana RN license required


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