RN Care Coordinator

Job Summary

The PCMH Pod Coordinator is responsible for ensuring high-quality, coordinated care for patients within their assigned care team (pod). This role supports care management, patient outreach, and pre-visit planning to advance the goals of the Patient-Centered Medical Home model. The PCMH Pod Coordinator collaborates closely with medical, dental, behavioral health, and administrative teams to enhance access, improve quality measures, and promote positive health outcomes.

Essential Duties and Responsibilities

Conduct daily team huddles with the pod to review schedules, identify care gaps, and coordinate outreach efforts. Review Epic Outside Events In-Basket messages and route appropriately to providers and care team members. Perform follow-up coordination after hospital discharges and emergency department visits. Monitor loop closure on referrals (internal and external) and document accommodations or barriers to care.

Identify high-risk patients and assist with chronic condition management by reviewing reports and flagging concerns. Facilitate interdepartmental referrals (e.g., medical to dental, behavioral health to social work). Assist with the creation and maintenance of patient care plans, including gathering input from providers and patients.

Contact patients to discuss health status, identify goals, and schedule necessary follow-up appointments. Conduct outreach to close care gaps (e.g., preventive screenings, immunizations, chronic disease monitoring). Review upcoming appointments to identify care opportunities and prepare outreach notes. Ensure medication accuracy and review pharmacy data for patients enrolled in care management.

Act as a MyChart ambassador to enroll and educate patients on how to use the portal. Gather patient-reported vitals using approved automated equipment. Maintain accurate patient attribution lists and assist in updating primary care assignments. Collaborate with the quality director to validate and report on payer-specific care gaps.

Complete timely and accurate documentation in the EHR and ensure closure of care coordination tasks. Participate in weekly debriefs and planning sessions with the Quality Director.

Qualifications

RN required. Minimum of 1 year experience in care coordination, patient outreach, or a clinical support role. Knowledge of the PCMH model and familiarity with quality metrics such as UDS, HEDIS, and ACO requirements. Strong communication and interpersonal skills. Proficiency with EHR systems (Epic preferred) and Microsoft Office.

Ability to work independently and as part of a multidisciplinary team. Work Schedule: Full-time, Monday through Friday, 8:00 AM – 5:00 PM with a 1-hour lunch break. Physical Requirements: Prolonged periods of sitting and working at a computer. Occasional walking, standing, or lifting up to 15 pounds. Work Environment: Office and clinic setting with frequent interaction with staff and patients.

May occasionally require travel between clinic sites.