RN Care Coordinator - Value Based Care (Charlottesville)
University of Virginia
- Charlottesville, VA
- Permanent
- Full-time
- Manages a patient panel, as assigned by the High Value team under Practice Innovation, with responsibility for improving performance on value-based contractual priorities.
- Conducts and documents assessment and a plan of care in Electronic Medical Recordkeeping (EMR) system.
- Consistently achieves established productivity and performance targets.
- Proactively identifies and prioritizes action items, including completion of preventive visits, care gap closures, and follow-ups after Emergency or Inpatient treatment.
- Reviews and monitors patient outcomes, recommends changes in care plan and implements population management interventions.
- Collaborates with interdisciplinary team to identify and address the needs of complex patients
- Continuously monitors progress on action items in care plan. Completes Chronic Care Management (CCM) documentation as appropriate.
- Actively participates in meetings, problem solving, goal setting, quality improvement and patient satisfaction initiatives.