RN Care Coordinator

ADP, Inc.; Fort Dodge (IA); On-site; USD 65,000 - 85,000; Full time

Job summary

ADP, Inc. Fort Dodge, IA is seeking a PCMH Pod Coordinator (RN) to ensure high-quality, coordinated care within the pod. You will support care management, outreach, and pre-visit planning to advance Patient-Centered Medical Home goals.

Responsibilities include daily team huddles, follow-up after discharges, handling referrals, and enrolling patients in MyChart. Strong EHR and communication skills are essential for this full-time role.

Qualifications

• RN license and experience in care coordination or clinical support.
• Strong communication and teamwork skills to coordinate care.
• Proficient with EHR systems and standard office software.

Responsibilities

• Conduct daily team huddles to review schedules and coordinate outreach.
• Review messages and route to providers and care team members.
• Follow up after hospital discharges and ED visits.
• Monitor referrals and document accommodations or barriers.
• Identify high-risk patients and assist with chronic condition management.
• Facilitate interdepartmental referrals and update care plans.
• Contact patients to discuss health status and schedule follow-ups.
• Close care gaps through preventive care outreach and monitoring.
• Review upcoming appointments and prepare outreach notes.
• Ensure medication accuracy and enroll patients in MyChart when needed.
• Gather patient vitals and maintain accurate attribution lists.
• Collaborate with quality to validate payer-specific gaps and report findings.
• Document thoroughly in the EHR and close care coordination tasks.

Skills

RN

Communication skills

Independent worker

Team collaboration

Education

RN license

Tools

Epic EHR

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

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.