Job Details
Community Care Rexburg - Rexburg, ID
Full time

The Care Coordinator supports Mountain View Hospitals initiatives toward clinical integration and accountable care strategies to achieve the triple aim in healthcare: 1) improving quality and patient satisfaction, 2) improving outcomes and the overall health of the population, and 3) reducing the total cost of care. Through risk stratification tools available to MVH, the Care Coordinator identifies patients with a need for early intervention related to discharge education, transitional care or disease management and coordinates intervention with PCPs and other care providers. The Care Coordinator also refers to medical and behavioral health providers as appropriate for further intervention.

  1. Solid understanding of the healthcare continuum
  2. Demonstrate sound judgment, patience and maintain a professional demeanor at all times
  3. Ability to work in a busy and stressful environment
  4. Organizational skills and the ability to prioritize
  5. Computer skills: Word, Excel, Outlook, Electronic medical records software
  6. Strong interpersonal verbal and written communication skills
  7. Ability to utilize data and reports to develop actionable interventions and measurable goals
  8. Creativity, complex problem analysis and decision making
  9. Ability to work varied shifts
  10. Stay current on CCM changes and requirements from CMS
  11. Manage and oversee the billing and payment of the CCM program
  12. Other tasks as assigned by the supervisor or physicians
  13. Manage gap reports
  14. Identify special needs and establish a care plan to follow when beginning to coordinate healthcare services.
  15. Act as a liaison between our provider and the patient when coordinating community resources, access to specialty services, follow-up healthcare, etc.
  16. Follow-up and help complete identified referrals. Coordinate with specialists and help to integrate recommendations from our provider. Identify barriers for lack of follow through or potential barriers to community resources.
  17. Conduct intermittent telephone consultations with high-risk clients to verify status of follow-up and determine if qualifying triggers have been satisfactorily resolved.
  18. Schedule complex clients for follow-up with provider and attend office visits if determined appropriate.
  19. Serve as the primary point of contact for patients considered “high risk.”
  20. Attend executive management meetings if indicated by invitation.
  21. Follow HIPAA guidelines when coordinating care


Education/Certification: Graduate with a degree in Registered Nursing. Must have a current Idaho license.  Care/Case Management or Population Health Management Certification (or ability to obtain certification within three years after hire) is required.

Experience:  To function effectively in this role, it is preferred that the candidatehave experience in both inpatient and outpatient care settings.  Health plan experience is a plus.  Past experience with Care/Case Management, Population Health Management, Utilization Review/Management is highly preferred.

Equipment/Technology: Must be able to use Microsoft Office, Word, and Excel. Adapt to computer systems quickly.

Language/Communication: Must have the sensitivity, maturity, and ability to communicate clearly and concisely, both verbally and in writing. Must be patient, courteous, compassionate, and respectful with patients and their families, co workers, physicians and administrative staff.  Ability to communicate and relate well with physicians, staff and management.

Mathematical Skills:  General mathematics

Mental Capabilities:  Ability to apply common sense to carry out instruction furnished in written, oral, or diagram form.  Ability to deal with problems involving several concrete variables in standardized situations.  A clear understating of the importance of patient confidentiality and sensitivity regarding complex health problems.  Maintian a positive attitude and willingness to jump in and help as you identify needs and upon request of the providers and team members.

Interpersonal:  Ability to work well with others as a team player.  Self motivated, self starter and initiative in establishing and developing the role of a care coordinator.  Organized, detail oriented, and the ability to manage a heavy load of complex patients.  Maintain a neat and professional appearance.