Care Coordinator - RN (Eastbank Market)

Job ID
Professional - All


Position Purpose

As part of the primary care patient centered medical home team, the RN Care Coordinator 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, ambulatory settings and in the member's home.  The Care Coordinator RN functions as part of a multidisciplinary team which includes a Navigator, Social Worker, Chronic Care Nurse, Pharmacist and Nurse Practitioner.


Scope of Position

Direct reports to Market Clinical Manager. Responsible for the management of an assigned population of members as part of the patient centered medical home model. Will also have responsibilities to maintain and ensure alignment with mission of Peoples Health as outlined in the mission statement.


Principal Responsibilities

  • Addresses the total individual, inclusive of medical, psychosocial, behavioral, cultural and spiritual needs
  • As appropriate, conducts comprehensive assessments of the member's health and psychosocial needs, including health literacy status and deficits
  • Involves the individual member and care giver, as appropriate, in decision making
  • Collaborates in efforts that focus upon moving the individual to self care when possible
  • 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
  • Provides prompt, courteous, excellent service to internal and external customers at all times
  • Facilitates communication and coordination between all members of the health-care team
  • 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
  • Educates the member, the family or caregiver, about disease states and treatments, plan benefits, community resources and resource options.  Evaluates the member's readiness and ability to learn
  • Encourages the appropriate use of health care resources
  • Collaborates with practice team members and market medical directors to facilitate appropriate treatment of members
  • Participates in medical home and market team meetings to improve member outcomes and Peoples Health processes
  • Review daily facility census for assigned population
  • When indicated by the needs of the patient (high risk, readmission, frequent Emergency Department visits, SNP) coordinates on-site reviews to develop a realistic discharge plan that will facilitate continuation of care at the most appropriate level.  Review will include quality of care, utilization pattern, and compliance with policy guidelines, in accordance with InterQual criteria
  • Coordinate discharge planning with facility Case Management and other Care Team staff for assigned members in all care settings.  Document appropriate in the Peoples Health CCMS system
  • Identify and plan all follow-up to hospital treatment with the medical home team and primary care physician.  Document review updates in CCMS update census, update discussions/events involving individuals responsible for a patient's welfare
  • Participate in meetings with PCP for review of the census as indicated
  • Communicate discharge information to the PCP Navigator
  • Coordinate with the PCP Navigator to facilitate the post hospital discharge visit within seven (7) days
  • Answer pages and phone calls received from hospital utilization review regarding a patient's condition during business hours
  • Develop referrals to appropriate resources to assist member and/or caregiver in continuation of care in an outpatient setting
  • If necessary, coordinated with he patient and/or caregiver to identify potential barriers to discharge to an alternate level of care
  • Participates with the medical home team in the monthly review of assigned members including Special Needs Plan (SNP)
  • Promote quality outcomes and participates in the measurement and understanding of those outcomes
  • Monitors performance against assigned members gaps in HEDIS and STAR measures through weekly report analysis
  • Utilizes evidence-based guidelines, as available, in their daily practice
  • Promotes a professional positive image of Peoples Health throughout the community. Identifies and communicates community concerns and problems affecting Peoples health to appropriate departments
  • Pursues professional excellence and maintains competence in practice through ongoing learning and education


  • Diploma or degree in nursing required; 
  • Bachelors in Nursing preferred. 
  • Minimum of 3 years health care experience as a RN required. 
  • Currently licensed as a RN in the State of Louisiana
  • Previous case management experience or previous managed care experience as a RN highly preferred.  
  • In-depth knowledge of utilization management, managed care delivery, Medicare and complex case management planning preferred.
  • Excellent verbal and written communication skills are required. 
  • Must be able to interface with multi-faceted medical professionals and non-medical staff.
  • Computer skills and knowledge of general office machinery required. 
  • Strong leadership and decision making skills are needed.  
  • Understanding of HMO and third party administration preferred. 


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