This position is part time: 32 hours per week.

Position Summary: The ACO Care Coordinator serves as a clinical resource supporting transitional care management, medication safety initiatives, and value-based care goals. The role focuses on ensuring smooth care transitions and collaboration with care teams, pharmacists, and community partners across the healthcare network to promote coordinated, safe, and effective patient care.

Key Responsibilities

Transitional Care Management (TCM)

• Timely outreach to patients post-discharge, conducting clinical assessments, addressing barriers to recovery, and assisting in care transitions from inpatient, SNF, or ED back to primary care.
• Complete medication reconciliation, patient/caregiver education, and timely scheduling of follow-up appointments.
• Document TCM interactions in the electronic health record according to ACO and CMS standards.

Pharmacy Services

• Collaborate with network pharmacist to complete medication reviews and support adherence and optimization for patients with polypharmacy or chronic disease.
• Identify and escalate medication-related safety concerns to pharmacy services.
• Deliver patient education regarding medication changes, side effects, and therapy goals.

Controlled Substance Stewardship

• Participate in the implementation of network-wide controlled substance monitoring protocols, collaborating with providers to ensure compliance and safety.
• Review patient histories for risk, support utilization of prescription drug monitoring programs, and provide education on safe use, storage, and disposal.

Population Health & Performance Improvement

• Engage in network quality initiatives aimed at reducing readmissions, improving medication adherence, and enhancing patient outcomes.
• Use data analytics to identify at-risk patients and develop targeted outreach strategies.
• Participate in cross-functional meetings to drive operational improvements.

Core Competencies

• Patient centered communication and coordination.
• Strong communication and patient education skills.
• Proactive problem-solving and time management.
• Data review and documentation accuracy.
• Demonstrate flexibility/adaptability in a team based environment.
• Commitment to patient safety, satisfaction, and value-driven care.

Other Responsibilities

• Centralized remote role with regular phone/electronic outreach, EHR review, and virtual team meetings.
• Performs all other duties as assigned by the supervisor and/or designee

Education & Experience

• Registered Nurse (RN) with active state licensure; BSN preferred.
• Minimum of 3 years’ experience in primary care, case management, or population health settings.
• Skilled in telephonic and virtual patient communication, clinical assessment, and coordination across settings.
• Proficient in using EHRs, and population health analytics tools.
• Familiarity with CMS Care Coordination Services standards and guidelines.
• Ability to collaborate effectively communicate across multidisciplinary and multisite teams.