FT Care Coordinator

  • Daniels Memorial Healthcare Center
  • Daniels Memorial Healthcare Center, Scobey, MT
  • Sep 01, 2021
Full Time Nursing

Job Description

JOB SUMMARY: Perform tasks to help coordinate the care of patients who require complex care and follow-up.  Use data and EHR to gather information and track patient’s health.  Will require initial implementation and developing processes and workflows as well as updating these processes periodically.


  1. Integrated behavioral health
  2. Inputs data into spreadsheet or program and utilizes information to assist with patient care.
  3. Utilizes interview and patient record review to identify actual or potential barriers and care needs
  4. Serves as a liaison between hospital, clinic and community agencies to facilitate the exchange of clinical and referral information
  5. Interacts with patient’s, support systems, healthcare professionals, and community and state agencies
  6. Discusses evaluations, goals and treatment’s with patients and support systems in order to enhance patient and support system engagement
  7. Collaborates with the multidisciplinary team to identify needs of patients and their support systems.
  8. Monitors PHQ2 an dPHQ9 trends for patients
  9. Follow up phone calls at 1-2 weeks, one month and 2 months (unless seen in clinic) with new medication changes or dose changes
  10. Helps navigate the patient through the healthcare system by being a contact point when utilizing different services and providers
  11. Provides educational materials and list of resources to patients and families
  12. Knowledgeable regarding insurance reimbursement, community resources and ancillary clinical services
  13. Supports psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects and effectiveness of treatment
  14. Provides brief behavioral interventions using evidence based techniques such as behavioral activation, problem-solving treatment, motivational interviewing or other interventions as appropriate
  15. Complete any assessments ordered by provider and input into medical record. Make provider aware of results.
  16. Find financial resources for medications and treatment’s
  17. Assist in lining up transportation for out of town visits.
  18. Will correctly bill for time when appropriate.
  19. Integrate care between mental health providers and primary care providers


  1. Chronic Care Management – rural health clinic
  2. Monitor quality of care for patients 18 and older with the following diagnosis
  3. essential hypertension
  4. type 2 diabetes without complications
  5. hypothyroidism
  6. acute respiratory infections
  7. In conjunction with medical staff, determine measure to be met with each diagnosis
  8. Ensure data is collected and documented with each clinic visit
  9. Create and maintain tracking record for tracking measures, scheduling labs, medication refills, appointments
  10. Provide educational materials regarding disease processes to patients
  11. Work with management to establish benchmark from number of patients that qualify the number of patients that have visits and the number of measures that have been met for each diagnosis.
  12. Work with informatics to identify patients with the above diagnosis
  13. Apply appropriate billing codes to encounters



  1. Medicare annual Wellness Visits
  2. Work with informatics to identify patients who qualify for the benefit
  3. Reach out to patients to schedule initial and follow-up exams
  4. Assist in data collection, screening and referrals for initial preventative exams
  5. Assist in data collection, screenings and referrals for preventative yearly exams
  6. Follow up with patients as needed
  7. Apply appropriate billing codes to encounters



  1. must be able to lift 50 pounds
  2. able to handle the emotional and mental stress that comes with the diverse population
  3. Possible travel for training
  4. Ability to sit/stand and work at computer for long periods of time



  1. RN/LPN license
  2. Able to obtain Motivational Interviewing training
  3. Other certifications related to job that become available.



Employment Type (feed only)

Full Time