Gritman Medical Center

RN Care Coordinator (ACO)

Job ID
# of Openings
Gritman Medical Center
Full Time


This position is Full-Time, Exempt, Benefited


Shifts: 8am-5pm, Monday-Friday


Job Summary:

Coordinates team-based care to provide health services to individuals, through
effective partnerships with patients, their caregivers/families, community
resources, and their physician. Facilitates a “shared goal model” within and
across settings to achieve coordinated high-quality care that is patient- and


Minimum Education
  • Graduate of an accredited school of nursing. BSN preferred
  • Current licensure as a Registered Nurse required in State of Idaho or Multi State License
  • BLS is required
Minimum Work Experience
• Previous experience in caring for chronic disease patients required.
• 3-5 years experience in clinical or community health settings preferred.
• Previous Care Coordination, Case Management or Home Health experience preferred.
Required Skills
• Demonstrates evidence of essential leadership, communication, education, collaboration, and counseling skills.
• Proficient in communication technologies (email, cell phone, etc.).
• Effective organizational skills and demonstrates ability to maintain accurate notes and records.
• Previous experience with health IT systems and data reports preferred.
• Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
• Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.


Position Competencies
• Core values consistent with a patient/family-centered approach to care.
• Demonstrates professional and effective written and verbal communication skills.
• Demonstrates a positive, respectful attitude and professional customer service.
• Acknowledges patients’ rights on confidentiality issues, maintains patient confidentiality at all times, and adheres to HIPAA guidelines and regulations.
• Proactively acts as a patient advocate, responding with empathy and respect to resolve patient/family concerns.
• Recognizes and responds to opportunities for improvement.
• Demonstrates continual learning skills, effects changes in approach to care based on established, evidence-based practice.
• Demonstrates professional practice behavior.
• Provides mentoring/coaching of other population health and care coordination team members.
• Cultivates effective partnerships, effectively collaborates with all practice providers (Physician, Nurse Practitioner, Physician Assistant and other licensed allied health team-members).
• Demonstrates understanding in use of IT resources and patient databases.
• Demonstrates effective delegation skills to streamline operational workflows and optimize inter-office resources.
Essential Functions
• Provide a coordinated, strategic approach to detect early and manage effectively the chronically ill patient population.
• Implement an effective internal tracking system for identified patients.
• Coach patients/families toward successful self-management of their chronic disease.
• Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
• Assess patient and family’s unmet health and social needs.
• Provide effective communications to improve health literacy.
• Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
• Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
• Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
• Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists (e.g., Diabetes Educator).
• Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
• Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources.
• Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
• Develop systems to prevent errors (e.g., effective medication reconciliation and shared medical records).
• Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed. 
• Attend and actively participate in all Care Coordination related training and meeting activities (Health Coach certification, quarterly Regional Workshops, monthly cohort calls with other ACO Care Coordinators and Coach).
• Serve as point of contact for Million Hearts Cardiovascular Risk Reduction Program. Screen eligible patients and collect required data. Provide education about program and risk reduction strategies to staff and providers. Develop program to facilitate ongoing management of high risk population
• Facilitate annual ACO quality reporting to include both clinical measures and MIPS. Utilize quality reporting dashboards to monitor ongoing performance. Provide education about measures and measure satisfaction to staff and providers. Complies, validates and reports ACO quality data. 
• Partner with ACO champion to fulfill ACO requirements including compliance, steering committee preparation and presentation and other duties related to ACO operations.
• Collaborate with Gritman administration, clinic leadership, providers and staff to advance priority ACO programs, including Chronic Care Management, Transitional Care Management and Medicare Annual Wellness Visit programs
• Ensure that Gritman’s ACO programs are in alignment with CMS and regulatory body requirements for documentation, billing, reporting, and compliance
• Maintain and enhance processes and systems supporting the goals of the ACO


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