RN Care Coordinator

Community Health Center; Fort Dodge (IA); On-site; USD 65,000 - 85,000; Full time

Job summary

Community Health Center in Fort Dodge, IA is seeking a PCMH Pod Coordinator to lead care coordination within a dedicated care team. You will support outreach, pre-visit planning, and medication review, collaborating with medical, dental, behavioral health, and admin teams to improve access and outcomes.

This full-time role requires RN licensure and strong communication; Epic experience is preferred to support efficient care coordination and patient education in a busy clinic setting.

Qualifications

• RN licensed and eligible to practice.
• 1+ year experience in care coordination or clinical support.
• Knowledge of PCMH model and quality metrics (UDS, HEDIS, ACO).
• Strong communication and interpersonal skills.
• Proficient with EHRs (Epic preferred) and Microsoft Office.

Responsibilities

• Conduct daily team huddles to review schedules and coordinate outreach.
• Review Epic Outside Events In-Basket messages and route to providers and care team members.
• Coordinate post-discharge follow-up and care transitions.
• Monitor referrals and document accommodations or barriers to care.
• Identify high-risk patients and assist with chronic condition management.

Skills

Care coordination

Patient outreach

Communication

Multidisciplinary teamwork

Independent work

Education

RN license

Tools

Epic

Microsoft Office

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Fort Dodge, IA, US

3 days ago Requisition ID: 1145

Salary Range: $65,000.00 To $85,000.00 Annually

Job Summary:

The PCMH Pod Coordinator is responsible for ensuring high-quality, coordinated care for patients within their assigned care team (pod). This role supports care management, patient outreach, and pre-visit planning to advance the goals of the Patient-Centered Medical Home model. The PCMH Pod Coordinator collaborates closely with medical, dental, behavioral health, and administrative teams to enhance access, improve quality measures, and promote positive health outcomes.

Essential Duties and Responsibilities:

• Conduct daily team huddles with the pod to review schedules, identify care gaps, and coordinate outreach efforts.
• Review Epic Outside Events In-Basket messages and route appropriately to providers and care team members.
• Perform follow-up coordination after hospital discharges and emergency department visits.
• Monitor loop closure on referrals (internal and external) and document accommodations or barriers to care.
• Identify high-risk patients and assist with chronic condition management by reviewing reports and flagging concerns.
• Facilitate interdepartmental referrals (e.g., medical to dental, behavioral health to social work).
• Assist with the creation and maintenance of patient care plans, including gathering input from providers and patients.
• Contact patients to discuss health status, identify goals, and schedule necessary follow-up appointments.
• Conduct outreach to close care gaps (e.g., preventive screenings, immunizations, chronic disease monitoring).
• Review upcoming appointments to identify care opportunities and prepare outreach notes.
• Ensure medication accuracy and review pharmacy data for patients enrolled in care management.
• Act as a MyChart ambassador to enroll and educate patients on how to use the portal.
• Gather patient-reported vitals using approved automated equipment.
• Maintain accurate patient attribution lists and assist in updating primary care assignments.
• Collaborate with the quality director to validate and report on payer-specific care gaps.
• Complete timely and accurate documentation in the EHR and ensure closure of care coordination tasks.
• Participate in weekly debriefs and planning sessions with the Quality Director.

Qualifications:

• RN required.
• Minimum of 1 year experience in care coordination, patient outreach, or a clinical support role.
• Knowledge of the PCMH model and familiarity with quality metrics such as UDS, HEDIS, and ACO requirements.
• Strong communication and interpersonal skills.
• Proficiency with EHR systems (Epic preferred) and Microsoft Office.
• Ability to work independently and as part of a multidisciplinary team.

Work Schedule:

• Full-time, Monday through Friday, 8:00 AM – 5:00 PM with a 1-hour lunch break.

Physical Requirements:

• Prolonged periods of sitting and working at a computer.
• Occasional walking, standing, or lifting up to 15 pounds.
• Office and clinic setting with frequent interaction with staff and patients.
• May occasionally require travel between clinic sites.