Accountable Care Organization Care Coordinator – Registered Nurse – Remote

Dartmouth Health

New Hampshire, United States Full-time in Healthcare & Medical
    • Job ID 1496287

    Job Description


    This is a remote position but within a commutable distance to Dartmouth Hitchcock in New Hampshire

    Identifies opportunities for the D-H attributed patients in our risk contracts to improve the health and reduce cost for that patient population. Provides health screening, assesses social determinants of health, and participates in care management and transitional care management to improve clinical quality. Functions as a resource to patients and families, partners with primary care, and is a conduit to D-H payer contracts to provide comprehensive patient-family centric care with a focus on improving D-H status in risk contracts.


    1. Manages and coordinates clinical care of defined populations with identified preventative care and/or chronic disease needs. Rounds at non-DH system hospitals to augment the transitional care management course for patients admitted to non-DH hospitals. This rounding includes meeting with patients while inpatient, assessing needs and barriers, and working with the patient, family, inpatient team, and ACO team to ameliorate issues and barriers that may impact care post-discharge and influence a potential readmission
    2. Identifies and assesses chronic disease patients. Performs a focused nursing assessment to include health and disease management, functional status, cognitive/mental status, nutritional status, available support system, cultural requirements, spiritual needs, identify psycho-social-financial concerns and assesses environmental limits and strengths. Identifies patients / families at high risk requiring on-going coordination of care. Facilitates the development of a comprehensive interdisciplinary disease management plan of care, with the patient, family and all members of the medical home team. Assesses unmet needs, strengths and assets of patients and their families.
    3. Participates in the development of disease management strategies for the ACO and identifies appropriate measures for the evaluation of outcomes. Determines potential focus for groups of patients using available data and tools.
    4. Contributes to the development and maintenance of a care delivery system which is patient/family centered and promotes effective resource utilization.
    5. Assists in collecting and evaluating clinical and financial data/outcomes including patient satisfaction, health and functional status, resource utilization, cost and role effectiveness. Identifies and recommends opportunities for improvement in the system. Leads or participates in quality improvement projects for the practice, especially related to the management of patients with chronic illness. Participates in case conferencing in conjunction with peers and the clinical team. Assists in the development of department annual goals and the identification of outcomes for continuous quality improvement.
    6. Determines eligibility for coaching intervention and determines need for supportive services and makes appropriate referrals.
    7. Acts as a patient advocate utilizing the essential activities of case management: assessment, planning, implementation, coordination, monitoring and evaluation.
    8. Establishes collaborative partnerships with patients and families to assist them in examining patterns of their health care needs and decisions, lifestyle choices, and utilization of resources that affect their health.
    9. Performs comprehensive assessment of patient situation and functioning to identify individual needs in order to develop a plan of care that will address those needs. Identifies actual or potential obstacles to discharge goals and report these to healthcare team.
    10. Assists with coordination of services through the continuum of care that balances the delivery of quality care with the cost effective utilization of resources. Executes activities and/ or interventions that will accomplish the case management plans.
    11. Reviews discharge instructions with patient and family and identifies ongoing education needs that exist.
    12. Performs other duties as required or assigned.


    • Graduate from an accredited Nursing Program required.
    • Bachelor of Science Degree in Nursing (BSN) and 3 years of clinical experience including 2 years of recent experience in ambulatory care or Care Coordination required.
    • Excellent assessment, communication, interpersonal, and organizational/time management skills.
    • Demonstrated ability to work well as a member of a team and respond calmly and effectively in a fast paced environment.
    • Excellent verbal and written communication skills.
    • Sound decision making, judgment, time management and negotiating skills.
    • Familiarity with electronic medical records, and computer applications including MS Word and Excel.
    • Must demonstrate passion for care of patients with chronic disease.
    • Sound decision making, judgment, and negotiating skills.
    • Knowledge of methods to educate and counsel patients, assess their readiness for changing health behaviors.

    Required Licensure/Certifications

    – Licensed Registered Nurse with New Hampshire eligibility. – Basic Life Support (BLS) Certificate required.

    Don’t meet every single requirement?

    Studies have shown that women and people of color are less likely to apply to jobs unless they meet every single qualification. At Dartmouth Hitchcock Medical Center and Clinics, we are dedicated to building a diverse, inclusive and authentic workplace, so if you’re excited about this role but your past experience doesn’t align perfectly with every qualification in the job description, we encourage you to apply anyway. You may be just the right candidate for this or other roles.

    • Remote: Fully Remote;
    • Area of Interest: Nursing;
    • FTE/Hours per pay period: 1.00 – 1.00 – 40 hrs/week;
    • Shift: Day;
    • Job ID: 20605;

    There are so many reasons to join Dartmouth Hitchcock Medical Center and Clinics, members of Dartmouth Health , the premiere health system in New England.

    First and foremost are our people. No matter the role, you ll find a shared purpose here. We have doctors ready to teach their knowledge, nurses who lead through experience, and other like-minded individuals collaborating for the health of the community, while inspiring each other day after day.

    Career development

    Affiliated with Dartmouth College, the atmosphere here is very collegial. You ll discover educational and research opportunities around every corner. At Dartmouth Hitchcock Medical Center and Clinics, you never stop learning.

    You ll also appreciate the resources our wide-spread health care system provides. You ll have access to experts at the top of their fields, advanced technologies, and modern facilities that enable you to care for patients like nowhere else.

    Benefits and wellness

    We offer a total compensation package that includes competitive health and wellness benefits. These benefits consist of “Core Benefits” that are provided by Dartmouth Hitchcock Medical Center and Clinics as well as “Benefit Choices” that allow you to select additional benefits to meet your personal situation and needs.

    Our locations

    New England is a very special place to live, work, and become part of a community. We have some of the most advanced educational institutions, best health care, and diverse cultural and recreational offerings you will find anywhere in the country. The public schools are excellent, the mountains are beautiful, and the lakes are pristine. No wonder so many people love it here.

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