RN Care Coordinator - PCMH Care & Outcomes Lead

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

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.