RN CARE COORDINATOR

About the role

Covenant Medical Group, the employed and managed medical practice organization of Covenant Health, provides comprehensive care across East Tennessee. With more than 300 physicians and advanced practice providers in 20 communities, the organization delivers a broad spectrum of specialties, from primary care and walk‑in clinics to preventive medicine and advanced surgical and subspecialty services. The Registered Nurse Care Coordinator, Chronic Care Management, functions as a liaison who works collaboratively with patients, physicians, and community referral sources to manage and improve health conditions through education and coordination of additional services.

Responsibilities

• Provides guidance and supervision for Care Navigators to ensure a collaborative approach to care management services.
• Carries out key functions related to patient outreach, quality reporting, performance measurement, and acts as a liaison between physicians and patients.
• Performs outreach to patients identified with chronic conditions that meet program eligibility requirements.
• Assesses, identifies, and prioritizes individual patient needs while building rapport and trust.
• Reviews and assesses member data—including clinical history, outpatient/inpatient treatments, emergency‑room visits, medications, and chart reviews—to monitor adherence to prescribed care plans.
• Collaborates with patients and providers to identify opportunities for optimizing care and closing gaps.
• Facilitates patient understanding of the physician’s treatment plan, including prescriptions, refills, medical supplies, referrals, service authorizations, and when to seek care.
• Assesses patients and families to evaluate social, emotional, functional, and physical health status.
• Promotes education by supplying informational materials and directing patients to appropriate community agencies and facilities.
• Understands, assists, educates, and facilitates the overall plan of care for patients with chronic conditions.
• Serves as a liaison between the practice and insurance payors regarding care and treatment options for chronic patients.
• Supports preventative care by promoting screenings, lifestyle coaching, and ongoing follow‑up.
• Provides education to providers, office managers, and clinic staff on quality initiatives and clinical documentation improvement.
• Maintains continuity of care among coordination team members by documenting and communicating actions, opportunities, and ongoing needs.
• Ensures evidence‑based practice guidelines are incorporated into patients’ plans of care.
• Assists in coordinating transitions of care for designated patient populations.
• Monitors care processes to implement cost‑effective utilization management and patient‑care initiatives.
• Ensures effective communication with payer care‑coordination teams to collaborate on patient‑care strategies.
• Develops strategies to decrease unnecessary emergency‑room utilization and hospital readmissions.
• Reviews and analyzes quality data to prioritize patient goals and develop care‑management strategies.
• Demonstrates knowledge of payer contracts, required quality metrics, and payer resources to support care coordination.
• Demonstrates knowledge of HEDIS, HCCs, and Medicare Risk Adjustment and their impact on pay‑per‑performance contracts.
• Performs other duties as assigned or requested.

Requirements

• Three to five (3‑5) years experience in a clinical setting; case‑management experience preferred.
• Computer literate with basic knowledge of Microsoft Office programs.
• Ability to build rapport and engage patients in effective dialogue related to their treatment plan.
• Ability to quickly identify and prioritize patient needs and provide structured, focused support and interventions.
• Exceptional critical‑thinking, analytical, and creative problem‑solving skills.
• High level of independence, organization, and interpersonal skills.
• Strong communication skills.
• Education: Not specified; must meet standards for RN licensure in Tennessee.

Licensure

Registered Nurse (RN) with an active license in the state of Tennessee.

Schedule

Full‑time, 80 hours per pay period, Day shift.