Job Title Clinical Care Coordinator Agency Texas A&M University Health Science Center Department Rural And Community Health Institute Proposed Minimum Salary Commensurate Job Location College Station, Texas Job Type Staff Job Description Our Commitment Texas A&M University is committed to enriching the learning and working environment by promoting a culture that respects all perspectives, talents & lived experiences. Embracing varying opinions and perspectives strengthens our core values which are: Respect, Excellence, Leadership, Loyalty, Integrity, and Selfless Service. Who we are As one of the fastest-growing academic health centers in the nation, Texas A&M Health encompasses five colleges and numerous centers and institutes working together to improve health through transformative education, innovative research and team-based health care delivery. What we want The RN Care Coordinator works with rural healthcare providers supporting patient outreach, chronic disease management, and patient engagement to improve quality of care, help manage chronic conditions, and promote wellness. Creates patient-centered care plans and provide care management services for provider clinics. Serves as a team member of the Texas Rural Engagement Program care coordination team extending patient management services and supporting team members promoting high quality care and financial viability. Helps to improve performance and initiatives in alternative payment models for rural healthcare. What you need to know Other Requirements and Factors: This position may require up to 30% or more travel. This position may allow an alternate work location per TAMU guidelines. Required Education and Experience: + Associate’s degree in Nursing + Four years of clinical experience as a Registered Nurse (or eight years of clinical experience as a Licensed Vocational Nurse) including two years of experience in basic data analysis, quality improvement, chronic care management, transitional care management, HEDIS medical record review, or preventive care. An equivalent combination of education and experience may be considered. Required Licenses and Certifications + Current unrestricted Registered Nurse license or Licensed Vocational Nursing (LVN/LPN) license in state of Texas Preferred Qualifications + Bachelor’s Degree in Nursing Preferred + Experience engaging with patients via remote interactions + Healthcare chronic care management, quality improvement, or transitional care management experience. + Experience working in or collaborating closely with primary care clinic setting + Working knowledge of spreadsheet, database software. + Thorough knowledge/understanding of claims/coding analysis, requirements, and processes. + Working knowledge of Microsoft Excel, Access, OR other spreadsheet/database software. + Case Manager Certification + Experience in basic data analysis, quality improvement, or HEDIS medical record review, preventive care, or health plan experience preferred Knowledge, Skills, and Abilities + Ability to effectively communicate both orally and in writing + Ability to positively and professionally interact with clients and staff + Excellent communication and presentation skills + Strong interpersonal and organizational skills + Working knowledge of office software and instructional programs + Skilled in patient engagement, motivational interviewing, and patient activation methods + Ability to multitask and work cooperatively with others + Ability to interpret reporting and set a plan of action + Self-motivated and self-directed + Knowledge of administrative functions, clinic quality measures, and scheduling experience Responsibilities: Care Coordination + Coordinates, monitors, and documents quality interventions and care management programs with goal of effectiveness that promotes value added care and service. + Creates patient centered care plans focusing on improved health and wellness. + Ensures members discharging from hospitals or emergency departments receive necessary services and resources, including medication reconciliation. Health Assessments + Carries out preventative health assessments, screening, and patient needs for effective transition of care planning to a variety of levels of care. + Triages symptom-based calls per approved protocols for a wide range of patients. + Makes outbound calls to assess patients’ current health status. Patient Education, Outreach, & Collaboration + Provides patient education to assist with self-management of wellness and disease. + Educates enrolled members on chronic and acute disease processes. + Interacts with clinic care partners, leadership and/or physicians to discuss clinical questions, concerns, strategies, and care plans to achieve quality and cost management objectives. + Functions as a liaison when needed for family, member, and provider to develop individualized care plans, including prioritized goals, that consider the patient’s and caregivers’ goals, preferences and desired level of involvement in the care management plan. Quality Monitoring + Evaluates utilization patterns, medical records, and other metrics to monitor quality and efficiency results. Why Texas A&M University? We are a prestigious university with strong traditions, Core Values, and a community of caring and collaboration.  Amenities associated with a major university, such as sporting and cultural events, state-of-the-art recreation facilities, the Bush Library and Museum, and much more await you.  Experience all that a big city has to offer but with a reasonable cost-of-living and no long commutes.  + Medical, (https://www.tamus.edu/benefits/medical/) prescription drug, dental, (https://www.tamus.edu/benefits/dental/) vision, life and AD&D, (https://www.tamus.edu/benefits/life-add/) flexible spending accounts , and long-term disability insurance (https://www.tamus.edu/benefits/long-term-disability/) with Texas A&M contributing to employee health and basic life premiums + 12-15 days (https://employees.tamu.edu/employee-relations/leave/index.html) of annual paid holidays + Up to eight hours of paid sick leave (https://employees.tamu.edu/employee-relations/leave/paid/sick.html)  and at least  eight hours of paid vacation (https://employees.tamu.edu/employee-relations/leave/paid/vacation.html)   each month + Automatically enrollment in the  Teacher Retirement System of Texas (https://www.trs.texas.gov/Pages/Homepage.aspx) + Health and Wellness: Free exercise programs and release time (https://flourish.tamu.edu/wellness-release-time/) + Professional Development: All employees have access to free   LinkedIn Learning (https://linkedinlearning.tamu.edu/)  training, webinars, and limited financial support to attend conferences, workshops, and more + Educational release time and tuition assistance (https://livingwell.tamu.edu/employee-tuition-assistance)   for completing a degree while a Texas A&M employee + Living Well, (https://livingwell.tamu.edu/) a program at Texas A&M that has been built by employees, for employees Instructions to Applicants: Applications received by Texas A&M University must either have all job application data entered, or a resume attached. Failure to provide all job application data or a complete resume could result in an invalid submission and a rejected application. We encourage all applicants to upload a resume or use a LinkedIn profile to pre-populate the online application. All positions are security-sensitive. Applicants are subject to a criminal history investigation, and employment is contingent upon the institution’s verification of credentials and/or other information required by the institution’s procedures, including the completion of the criminal history check. Equal Opportunity/Affirmative Action/Veterans/Disability Employer.