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MUSCP - Patient Centered Medical Home RN Care Coordinator III

Apply now Job no: 514161
Entity: MUSC Physicians
Department: Bu/College Of Medicine
Sub Department: UMA01-013-DPT/Family Medicine
Work type: Full-Time
Employee Type: MUSCP - Staff
Location: Charleston, SC
Categories: Case Management
Pay scale: MUSCP-G13: $46,516 - $79,159


Entity/Organization:  MUSC Physicians (MUSCP) 

Hours per week:  40 

Scheduled Work Hours/Shift:  8am-5pm 

Pay Basis/FLSA:  Hourly 

Job Summary/Purpose: The role of the Patient-Centered Medical Home (PCMH) Care Coordinator  is a nurse that works collaboratively with the physicians, staff and other health care professionals to actively facilitate health care delivery and promote care team communication for an assigned patient population ensuring appropriate care is provided. 

Minimum Training and Education: Have 5 years of relevant medical office experience required. Current South Carolina RN required with a minimum three years’ experience as an RN. Computer skills to include proficiency in MS Word, Excel and PowerPoint. Working knowledge of an electronic medical record application. A team player that can follow processes to achieve a common goal. Highly organized and well-developed oral and written communication skills. Must be able to analyze and interpret data. 

Required Licensure, Certifications, Registrations: Current South Carolina RN license 

Additional Duties and Responsibilities: 

  • Identifying patients that qualify for care coordination : discharge from facility (TCM), are not meeting clinical goals and ACO measures (i.e. hypertension and diabetic control), overdue for visits, labs, or referrals and arranging for follow-up services as appropriate, chronic care management (CCM)
    • Utilizes Epic registries and reports in accordance with process (i.e. TCM-daily, CCM-weekly & daily, ACO measures) to identify patients and needs
    • Outreached  to patients identified for care coordinator services (i.e. TCM,CCM, ACO measures)  & documents attempt (s) & completion
    • Scheduled services and places referrals in accordance with patient need (s) (i.e. vaccine, labs, appointment, mammogram, etc.)
    • Follow up as appropriate to track data
    • Accurately maintains 100% of data received.
    •  
  • Communicates effectively and professionally  with patient (s), care team (s) and providers to provide support for continuity of care between patient, care team, and assigned providers
    •  Compiles  and summarize information for quality measures and projects
    • Attend 80 % of staff meetings
    • Maintains communication with providers & care team members (I.e. Epic inbox message, email, phone, office schedule,  in person)
  • Identify patient needs and/or barriers (psychosocial and other) to care and coordinate patients/families contact with community resources.
    •  Completes & documents accurate information gathering of data
    • Completes Epic & community referrals as needed
    • Communicates & follow up of identified barriers to the appropriate care team member/resource
    • Other duties as assigned.

Physical Requirements: Continuous requirements are to perform job functions while standing, walking and sitting. Ability to bend at the waist, kneel, climb stairs, reach in all directions, fully use both hands and legs, possess good finger dexterity, perform repetitive motions with hands/wrists/elbows and shoulders, reach in all directions. Maintain 20/40 vision corrected, see and recognize objects close at hand and at a distance, work in a latex safe environment and work indoors. Frequently lift, lower, push and pull and/or carry objects weighing 50 lbs (+/-) unassisted, exert up to 50 lbs of force, lift from 36” to overhead 25 lbs. Infrequently work in dusty areas and confined/cramped spaces. Ability/willingness to travel frequently to MUSCP-PC clinical locations away from the main campus.

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.


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The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.