Guthrie · 18 hours ago
RN Care Coordinator Wellness - Strategic Insurance Development - Per Diem
1 Guthrie Square, Sayre, PA, 18840, US
Full-time
Onsite
Senior Level
5+ years expGuthrie is a non-profit, integrated healthcare organization providing primary and specialty care. The RN Care Coordinator will assist in coordinating the medical management of patients, focusing on health promotion and illness prevention while collaborating with the healthcare team to develop care plans for at-risk patients.
Health CareHospitalPersonal Health
Responsibilities
Support Care Management functions in Primary Care Practices
Actively manages a panel of high-risk patients using motivational interviewing, shared decision making, and goal setting to increase patient/family engagement
Uses technology, such as tele-visits and remote monitoring capabilities, to engage patients and monitor chronic health conditions
Provide Transitional Care Management (TCM) following an inpatient stay for all identified patients
Collaborates with patient, physician, and other care team members in assessing the patients progress toward individual health care goals
Provides follow-up information for the patients indicated to ensure compliance with recommendations, medication, lab/x-ray, specialist visits, PCP visits, dieticians, CDE, etc
Supporting the PCMH initiative at the practice level through involvement with quality improvement initiatives, participating in PCMH/Population Health meetings, and educating on best practice models as needed
Support Medicare Annual Wellness Visit activities
Promotes wellness and illness prevention using clinical nursing knowledge of disease process, risk factor identification, and illness prevention strategies
Performs all elements of the Medicare AWV with beneficiaries in accordance with Documentation Standards Policy and the AWV Policy and Procedure
Develops a written, age appropriate, individualized prevention plan for each patient including, but not limited to, psychosocial/behavioral risk factors, physiological risk factors, age-appropriate preventative services, recommendations from the USPSTF, and vaccination schedule
Performs Nursing functions such as, but not limited to, providing immunizations, and collecting laboratory specimens
Maintains relevant nursing knowledge of evidenced based strategies related to health promotion and illness prevention, as well as management of chronic conditions
Support the primary care practice with the use of technology, including Microsoft and EPIC Software. Functionality would include reporting Workbench, Patient Outreach (eGuthrie, Health Maintenance, Care Everywhere, EPIC Care Link) and Disease registry tools
Travel for this position may be required
The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements as to his/her specific needs, and to provide the care needed as described in the appropriate policies and procedures
It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position
Qualification
Required
A minimum of five (5) years relevant clinical experience who demonstrates leadership and autonomy in nursing practice
Licensed Registered Nurse with 5 years' experience, preferably in an outpatient/ambulatory setting
Bachelor's Degree in Nursing or related field required
The Care Coordinator must have or receive prior to position start date, current licensure by the Commonwealth of Pennsylvania and New York State as a Registered Professional Nurse, as required
Preferred
Preferred experience with PCMH process, care management/utilization review, and payer knowledge
Fast paced ambulatory care experience preferred
Master's Degree preferred
With an employment agreement, will consider applicant who is actively pursuing their bachelor's degree
Company
Guthrie
Health care
5001-10000 employees
Funding
Current Stage
Late StageTotal Funding
unknownKey Investors
Fidelis Care
2025-05-14Grant
Leadership Team
Edmund Sabanegh
President & Chief Executive Officer, The Guthrie Clinic
Brad Carvellas
SVP, Chief Digital Officer
Recent News
Central New York Business Journal
2026-01-03
2025-12-24
2025-09-23
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