Overview Experience a rewarding and fulfilling career with Mercyhealth. Mercyhealth is committed to offering our partners a best place to work. Our unique workplace Culture of Excellence is built upon: Employee engagement, empowerment and growth Teamwork toward our common goal – providing exceptional health care services with a passion for making lives better An atmosphere of caring and quality that cascades throughout the organization Patient Care Coordinator's primary responsibility is to oversee panel management for the primary care patients of the practice, to monitor chronic disease management and support providers in both. This includes both proactively working with patients to receive needed services, and to also assist patients within the clinic setting to meet their desired health goals. Responsibilities Essential Duties and Responsibilities Actively case manages assigned panel of chronic care patients. Oversees the prevention care reminder program for the practice's patients, ensuring that patients receive reminders of the need for preventive or disease management screening and testing. Leads the physician care teams in ensuring a smooth transition of care for patients seen or treated in an ED, IC or as an inpatient. Coordinates the process of determining the needs of various sets of individuals, including those identified chronic care conditions, using Epic and registry reporting to determine which patients are overdue for: care; services; or testing. Develops a community resource list of services available to patients and maintains collegial relationships with community resources agencies used most frequently. Contacts patients between visits via telephone, email or MyChart to check on self-monitoring, provide encouragement and support, and assess patient progress toward health status goals; Participates in the process of incorporating evidenced based diagnosis and treatment guidelines into the management of patient panels. Acts as a resource to assist the Clinic Partners with Medical Home patients who are non-compliant with their plan care. Introduces new patients to their disease care plan in the Medical home. Certification and Licensure Licensed as an RN in the state of practice Skills and Abilities Excellent organizational skills Computer skills Self starter Works independently with little or no supervision. Spanish speaking preferred May include color blind test (per department guidelines) Special Physical Demands While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee must occasionally lift and or move up to 10 pounds.