Care Coordinator

Meharry Medical Group (MMG) – Meharry Medical Group is a team of multi-disciplinary health care providers whom practice through Meharry Medical College's School of Medicine to provide much-needed health care services to communities in Nashville and surrounding areas. Meharry physicians and health care providers are known in the community for delivering compassionate, patient-centered care for the entire family.

MMG is seeking a Care Coordinator for its outpatient medical practice. The ideal candidate will facilitate partnerships between patients, physicians and health care teams with a focus on care coordination and integration of treatment plans. The Care Coordinator will track and support patients when they obtain services inside the practice and outside the practice, and ensure safe and timely referrals or transitions by deliberately integrating patient care activities between two or more participants involved in a patient’s care. The main objective of the Care Coordinator will be to facilitate the appropriate delivery of health care services and reduce fragmented care by closing gaps in care.

• Linking patients with community resources to facilitate referrals and respond to social service needs
  • Assisting with the development of a preferred provider referral network
  • Proving social services support to the patients, including assisting with referral to community resources
  • Clinical Data Management, i.e., Coordinate all referrals through initiation and tracking; including follow-up by obtaining clinical documentation, labs, diagnostic test, etc. from external referral sources

• Tracking and supporting patients identified as high-risk and/or high utilizers of health care services and when they obtain services outside the practice
• Follow-up with patients within a few days of an emergency room visit or hospital discharge to coordinate follow-up services.

• Communicating test results and care plans to patients/families.

• Coordinating with the Behavior Health Specialist to integrating behavioral health and specialty care into care delivery through co-location or referral agreements

• Providing care management services for high-risk patients by:
  • Establishing targeting methods for identifying patients at high risk for hospitalizations, including patients with admissions for mental health related issues, and chronic health conditions (i.e. Diabetes, CVD, Asthma, Morbid Obesity)
  • Establishing a means of receiving timely access to hospital and emergency room admissions to ensure safe, effective and efficient transition back to the Primary Care Provider
  • Making in-person contact when possible
  • Maintaining close contact with the Primary Care Provider for integrated, patient-centered care
  • Collaborating with the interdisciplinary team, which includes the patient, to achieve coordinated and patient-centered goals and plans of care, including medication management, motivational interviewing, patient education on disease process, healthy living and self-management skills
• Management of follow-up appointments and tests/procedures

• Performs other related duties as assigned.

Education and Experience:
•Graduation from an accredited university with either an associate’s degree in nursing, a bachelor’s degree
in nursing, or a bachelor’s degree in social work or a licensed practical nurse with at least 10 years of
nursing experience.
•Valid Tennessee Nursing License in the state of Tennessee and/ or holds a Compact State Nurse License.
•1-year experience in a Patient-Centered Medical Home clinical setting or knowledge of the Patient-
Centered Medical Home Model of Care is preferred.
•1-3 years’ experience in Community Health, Care Coordination or an Integrated Healthcare model is
preferred.
•Experience with electronic medical records is preferred