JOB REQUIREMENTS: Pillar Health is looking for experienced RegisteredNurse Care Coordinators. \$5,000 hiring bonus - See below for details.POSITION SUMMARY The Registered Nurse Care Coordinator (RNCC) has avital role within the KCHC/Pillar Health integrated care model. As a keypartner to an assigned care provider(s) they support management of apatient panel using proactive and planned care goals while alsocoordinating the care team necessary to achieve them. The RNCCparticipates in the delivery of evidence-based care to an assignedpatient population utilizing defined care standards, identifying caregaps, ensuring efficient access to care, care planning, and facilitatingseamless care transitions and care continuity. The RNCC alsoparticipates in the analysis of outcomes, identification ofopportunities for improvement, and implementation of changes to optimizeoutcomes for individual patients and the overall population. Theposition of the RNCC in the care model places the role in a uniqueposition to facilitate an inter-professional team of clinicians in awraparound care coordination model that will identify and addresspatient emergent, chronic, preventative care and social needs placingplace patients in the best position for optimal health outcomes.ESSENTIAL FUNCTIONS The list of duties and responsibilities is not allinclusive and may be expanded to include other duties andresponsibilities, as management may deem necessary from time to time.Coordination and Management of the Patient Panel * Reviews and assessespatient registration data, including outpatient or inpatient treatments,emergency room visits, medications, chart reviews, to assist in themonitoring and facilitation of adherence to prescribed care plans. *Using the Electronic Health Record (EHR) and other electronic resourcesto identify patient care gaps and coordinate activities with theprovider and care team to close those gaps. * Utilizes organizationdefined risk stratification tools, EHR, and other electronic resourcesto risk stratify the assigned patient panel and track indicators of thepanel. * Chronic Care Management of medium, rising risk and high-riskpatients * Draw conclusions from available data to develop an overallstrategy for the assigned patient panel as a whole, and individualpatients in the different risk groups. * Routinely evaluates socialneeds that can negatively impact health outcomes. Connects patients toavailable resources to meet those needs. * Initiates or contributes tothe development and implementation of individualized, comprehensive careplans including medical and social needs. * Accesses internal andexternal resources to support development and implementation of... Forfull info follow application link. Kenosha Community Health Center is anEqual Opportunity employer. All qualified applicants will receiveconsideration for employment without regard to race, color, religion,sex, national origin, disability or veteran status. *****APPLICATION INSTRUCTIONS: Apply Online: ipc.us/t/A4BAAF874E0546D5