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Care Coordinator - Clinic - PIC Pocatello

Pocatello, Idaho
Job Type
19 May 2023
Mountain View Hospital is looking for a Care Coordinator - Clinic to join our team!


The Care Coordinator supports MVH's initiatives toward clinical integration and accountable care strategies to achieve the triple aim in healthcare: 1) improving quality and patient satisfaction, 2) improving outcomes and the overall health of the population, and 3) reducing the total cost of care. Through risk stratification tools available by Population Health, the Care Coordinator identifies patients with a need for early intervention related to discharge education, transitional care or disease management and coordinates intervention with PCPs and other care providers. The Care Coordinator also refers to medical and behavioral health providers as appropriate for further intervention.


Taking care for our community starts with taking care of our own team. Mountain View Hospital is proud to offer its employees competitive and comprehensive benefit packages. Benefits include:

Medical, Dental and Vision Insurance
Paid Time Off (vacation, holidays and sick days) and Medical Paid Time Off
Retirement Plans (401K with up to 6% match)
Earned Quarterly Bonus Program
Education Reimbursement Program
Discount for medically necessary procedures performed at Mountain View Hospital and Idaho Falls Community Hospital

Please note benefits are based on eligibility according to full-time, part-time or PRN status classification.


1. Work under direct supervision of nurse supervisor to provide excellent patient care to all clients.
2. Participate in the transition of the clinic into the ACO/PCMH.
3. Engages with population health team on Quality Based programs in the clinics.
4. Offers solutions to road blocks while implementing programs.
5. Run needed reporting to track MIPS and ACO measures
6. Run CCM and Annual Wellness Visit outreach reporting for all clinics to work through and help with outreach.
7. Monitor high risk patients within the clinic and follow up appropriately with clinic staff or RN care coordinator within Population Health.
8. Helps to ensure all deadlines are met during transition stages.
9. Offers education and tutoring to nurses involved in the program. May also provide
education to all providers if needed.
10. Will participate in webinars, conferences, education meetings, and transitional calls.
11. Is able to perform a head-to-toe assessment on all patients and performs reassessments as per policy. This includes: pediatric, geriatric, the general patient population, and EMTALA appropriate medical screening exams.
12. Have a solid understanding of the CCM program.
13. Revises Care Plans as indicated by the patient's response to treatment and provider direction.
14. Performs patient care responsibilities considering needs specific to the standard of care for patient's age.
15. Is knowledgeable of medications and their correct administration based on age of the patient and their clinical condition.
16. Follows the five medication rights and reduces the potential for medication errors.
17. Formulates a teaching plan based on identified patient learning needs and evaluates effectiveness of learning, family is included in teaching as appropriate.
18. Is able to perform treatments and provide services and education to level of licensure.
19. Treats patients and their families with respect and dignity. Identifies and addresses psychosocial, cultural, ethnic and religious/spiritual needs of patients and their families. Functions as a liaison between administration, patients, physicians and other healthcare providers.
20. Interacts professionally with patient/family and involves patient/family in the formation of the plan of care.
21. Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patient population served. Able to interpret data about the patient's status in order to identify each patient's age specific needs and provide care needed by the patient group.
22. Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.
23. Consults other departments as appropriate for an interdisciplinary approach to the patient's needs.
24. Communicates appropriately and clearly to manager, co-workers and physicians.
25. Maintains a good working relationship both within the department and with other departments within our organization.
26. Acts as a resource for other less experienced nursing staff to include additional staff educational duties as assigned.
27. Documentation meets current standards and policies.
28. Manages and operates equipment safely and correctly.
29. Coordinates and supervises patient care by coordinating with outside practices.
30. Is flexible, organized and functions under stressful situations.
31. Completes annual education requirements.
32. Maintains regulatory requirements.
33. Maintains patient confidentiality at all times. Reports to work on time and as scheduled, completes work within designated time.
34. Wears identification while on duty, uses computerized punch time system correctly.
35. Completes in-services and returns in a timely fashion.
36. Attends annual review and department in-services, as scheduled.
37. Attends at least 75% of staff meetings annually.
38. Represents the organization in a positive and professional manner.
39. Actively participates in performance improvement and continuous quality improvement (CQI) activities.
40. Solid understanding of the ACO.
41. Complies with all organizational policies regarding ethical business practices.
42. Flexible in scheduling, work weekends and holidays and work overtime when needed.
43. Maintain flexibility in a growing environment and be willing to grow, change and accept new duties as the scope of our department changes with the needs of the community and hospital.
44. Solid understanding of HCC coding and quality measures for all payors.
45. Training in, understanding of, and utilization of motivational interviewing during interaction with patients.
46. Understands care gap rosters and Optum

About Mountain View:

Mountain View Hospital and our 29 affiliate clinics are committed to providing compassionate, cutting edge care to our patients. We serve the entire Snake River Valley - all the way from Pocatello to Rexburg. Our medical capabilities span everything from wound care to urgent care, oncology to neurology, physical therapy to speech therapy, a Level III NICU, robust robotic surgery department and a continuously expanding rural health practice.

Our work environment is mission driven, people-centric and supportive. It is what sets apart and makes people excited to come to work each day. If you are looking for a career where you can make a difference in your community, we invite you to apply.

Education/Certification: Must have a Certificate in Medical Assisting (CMA) or a license in Practical Nursing (LPN), or Graduate with a degree in Registered Nursing (RN). Must have a current Idaho license. Care/Case Management or Population Health Management Certification (or ability to obtain certification within three years after hire) is required.

Experience: To function effectively in this role, it is preferred that the candidate have experience in both inpatient and outpatient care settings. Health plan experience is a plus. Past experience with Care/Case Management, Population Health Management, Utilization Review/Management is highly preferred.

Equipment/Technology: Must be able to use Microsoft Office, Word, and Excel. Adapt to computer systems quickly.

Language/Communication: Must have the sensitivity, maturity, and ability to communicate clearly and concisely, both verbally and in writing. Must be patient, courteous, compassionate, and respectful with patients and their families, co workers, physicians and administrative staff. Ability to communicate and relate well with physicians, staff and management.

Mathematical Skills: General mathematics

Mental Capabilities: Ability to apply common sense to carry out instruction furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations. A clear understating of the importance of patient confidentiality and sensitivity regarding complex health problems. Maintain a positive attitude and willingness to jump in and help as you identify needs and upon request of the providers and team members


Interpersonal: Ability to work well with others as a team player. Self motivated, self starter and initiative in establishing and developing the role of a care coordinator. Organized, detail oriented, and the ability to manage a heavy load of complex patients. Maintain a neat and professional appearance.
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  • Job Reference: 1010175361-2
  • Date Posted: 19 May 2023
  • Recruiter: Mountain View Hospital
  • Location: Pocatello, Idaho
  • Salary: On Application
  • Sector: Healthcare & Medical
  • Job Type: Permanent