Summary Care Coordinator/Wellness Nurse-Per Diem will assist in coordinating the medical management of patients, using an outcomes-based approach. In collaboration with other members of the healthcare team, the Care Coordinator identifies at risk patients, develops a plan of care, and coordinates care with the patient’s involvement. In addition, this position will also support health promotion and illness prevention for Medicare patient though completion of the Medicare Annual Wellness Visit. This position will work with physicians and other patient care providers as he/she supports PCMH and wellness initiatives in meeting quality process and performance objectives through data collection, data analysis and process outcome evaluation. Experience A minimum of five (5) years relevant clinical experience who demonstrates leadership and autonomy in nursing practice. Preferred experience with PCMH process, care management/utilization review, and payer knowledge. Fast paced ambulatory care experience preferred. Education Licensed Registered Nurse with 5 years’ experience, preferably in an outpatient/ambulatory setting. Bachelor’s Degree in Nursing or related field required. With an employment agreement, will consider applicant who is actively pursuing their bachelor’s degree. Master’s Degree preferred. Licenses The Care Coordinator must have or receive prior to position start date, current licensure by the Commonwealth of Pennsylvania and New York State as a Registered Professional Nurse, as required. Essential Functions + Support Care Management functions in Primary Care Practices + Actively manages a panel of high-risk patients using motivational interviewing, shared decision making, and goal setting to increase patient/family engagement. + Uses technology, such as tele-visits and remote monitoring capabilities, to engage patients and monitor chronic health conditions. + Provide Transitional Care Management (TCM) following an inpatient stay for all identified patients. + Collaborates with patient, physician, and other care team members in assessing the patients progress toward individual health care goals. + Provides follow-up information for the patients indicated to ensure compliance with recommendations, medication, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc + Supporting the PCMH initiative at the practice level through involvement with quality improvement initiatives, participating in PCMH/Population Health meetings, and educating on best practice models as needed. + Support Medicare Annual Wellness Visit activities + Promotes wellness and illness prevention using clinical nursing knowledge of disease process, risk factor identification, and illness prevention strategies. + Performs all elements of the Medicare AWV with beneficiaries in accordance with Documentation Standards Policy and the AWV Policy and Procedure. + Develops a written, age appropriate, individualized prevention plan for each patient including, but not limited to, psychosocial/behavioral risk factors, physiological risk factors, age-appropriate preventative services, recommendations from the USPSTF, and vaccination schedule + Performs Nursing functions such as, but not limited to, providing immunizations, and collecting laboratory specimens. + Maintains relevant nursing knowledge of evidenced based strategies related to health promotion and illness prevention, as well as management of chronic conditions + Support the primary care practice with the use of technology, including Microsoft and EPIC Software. Functionality would include reporting Workbench, Patient Outreach (eGuthrie, Health Maintenance, Care Everywhere, EPIC Care Link) and Disease registry tools. Other Duties + Travel for this position may be required. + The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures. + It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position. Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community. The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace. The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.