Field Care Coordinator, RN – Remote in Las Cruces, NM

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The RN Clinical Care Coordinator will be the primary care manager for a panel of members with complex medical/behavioral needs. Care coordination activities focus on supporting member’s medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care. This position is full – time (40 hours / week) Monday – Friday. Employees are required to have flexibility to work any of our 8 – hour shift schedules during our normal business hours of 8am to 5pm. It may be necessary, given the business need, to work occasional overtime. This position is a field – based position with a home – based office. If you reside in Las Cruces, New Mexico or within a commutable driving distance, you will have the flexibility to work remotely* as you take on some tough challenges.

Engage members face-to-face and/or telephonically to complete a comprehensive needs assessment, including assessment of medical, behavioral, functional, cultural, and socioeconomic needs Develop and implement person centered care plans to address needs including management of chronic health conditions, health promotion and wellness, social determinants of health, medication management and member safety in alignment with evidence-based guidelines Partner and collaborate with internal care team, providers, and community resources/partners to implement care plan Provide education and coaching to support member self-management of care needs and lifestyle changes to promote health Support proactive discharge planning and manage/coordinate Care Transition following ER visit, inpatient or Skilled Nursing Facility (SNF) admission Advocate for members and families as needed to ensure the member’s needs and choices are fully represented and supported by the health care team Ability to transition from office to field locations multiple times per day Ability to navigate multiple locations/terrains to visit employees, members and/or providers Ability to transport equipment to and from field locations needed for visits (ex. laptop, stethoscope, etc.) Ability to remain stationary for long periods of time to complete computer or tablet work duties