1+ months


Universal Health Services
Edinburg, TX 78539
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Position Summary:

The RN Care Coordinator is a registered nurse who functions in a leadership role in Population Health. S/he is a liaison between the patient and the multidisciplinary healthcare team to assist in developing and implementing a patient centered plan of care for high risk patients. The Care Coordinator assesses patients needs and coordinates resources within and outside the practice to promote optimal health benefits and quality outcomes in a manor most acceptable to the patient. S/he works in direct coordination with the local Managed Care Team and serves as an educational resource for providers. S/he works with the Quality Department to analyze and communicate population health data to meet the Triple Aim of Population Health.

Job Requirements


Bachelors Degree

Preferred - Masters Degree

Years of Related Experience



5 8

8 10

Required Knowledge, Skills, Licensure, Training & Travel Requirements (if applicable):

Education: Graduation from an accredited nursing education program. Licensed by the State to practice as a Registered Nurse. Training in Motivational Interviewing preferred

Work experience: Minimum of 5 years in case Management, Home Care or Hospice required

Knowledge: Motivational Intervening, Shared Decision Making, Patient Centered Medical Home principles

Skills: Certified Case Manager (CCM), Certifies. Critical thinking, problem solving, ability to work both independently and in teams, and ability to coach and mentor clinical and non-clinical staff

Abilities: Operate within the concept of patient centered care

Equipment Operated: Standard office equipment (laptop computer, fax, copier scanner)

Work environment: Outpatient medical office setting

Mental/Physical Requirements: Prolonged periods of sitting, multisite visits. Most work is telephonic

Essential Job Duties

% of Time


Service Excellence and Professionalism

  • Treat others as guests
  • Demonstrate professionalism and excellence
  • Practices teamwork
  • Possess a passion for doing the right thing for our patients and coworkers
  • Understand and practice the principles of patient centered care



Transitions of Care (TOC)

  • Contacts high risk patients within 2 business days of discharge to assure a safe landing
  • Completes Medication Reconciliation
  • Assesses for community resources at home and arranges for services
  • Creates patient centered care plan to avoid hospitalizations and emergency department visits
  • Assists the clinic in scheduling the TOC visit in 7 to 14 days
  • Follows up with patients for 30 days post discharge as clinically necessary
  • Mentors and coaches clinic staff in managing low risk patients



Longitudinal Care Coordination

  • Provide disease management and patient centered teaching to patients with multiple chronic disease
  • Help patients to utilize their care team to avoid ED visits
  • Assist patients in creating chronic condition care plans
  • Utilizes community resources to meet the patients needs




  • With the Quality Team, utilize population health data to identify and manage high risk patients, close gaps in care and assist in risk stratification
  • Ability to communicate population health data to the care team



Effective problem solving, process improvement and decision making

  • Advanced knowledge of evidence based best practice in chronic disease management, motivational interviewing and shared decision making
  • Critical; thinking skills
  • Principles of process improvement
  • Utilize principles of change management to assist the clinics to move to a patient centered, population health approach to primary care


Guidance Requirement: Indicate the degree to which the position is guided by the Supervisor/Manager. (Check one)

Direct supervision given. Specific/detailed instructions provided.

Procedures well established. Few decisions made. Supervisor readily available as needed.

Independent judgment necessary. Supervisor is usually available.

Little to no guidance provided by supervisor on daily basis.

Physical Effort Requirement: (Check One)

Minimal physical effort

Physical Effort found in normal office environment

Occasional strenuous effort (e.g. continuous typing, prolonged standing/bending, etc.)

Frequent/strenuous physical effort (e.g. lifting, moving heavy objects, etc.)

Posted: 2019-12-17 Expires: 2020-04-02

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Universal Health Services
Edinburg, TX 78539

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