RN Care Coordinator, Population Health

Job Locations US-WI-Janesville
Position Type
Active Full-Time Hourly
Mercyhealth Henry Palmer 903


Patient Care Coordinator’s primary responsibility is to oversee panel management for the primary care patients of the practice, to monitor chronic disease management and support providers in both. This includes both proactively working with patients to receive needed services, and to also assist patients within the clinic setting to meet their desired health goals.


  • Actively case manages assigned panel of chronic care patients.
  • Oversees the prevention care reminder program for the practice’s patients, ensuring that patients receive reminders of the need for preventive or disease management screening and testing.
  • Leads the physician care teams in ensuring a smooth transition of care for patients seen or treated in an ED, IC or as an inpatient.
  • Coordinates the process of determining the needs of various sets of individuals, including those identified chronic care conditions, using Epic and registry reporting to determine which patients are overdue for: care; services; or testing.
  • Develops a community resource list of services available to patients and maintains collegial relationships with community resources agencies used most frequently.
  • Contacts patients between visits via telephone, email or MyChart to check on self-monitoring, provide encouragement and support, and assess patient progress toward health status goals;
  • Participates in the process of incorporating evidenced based diagnosis and treatment guidelines into the management of patient panels.
  • Acts as a resource to assist the Clinic Partners with Medical Home patients who are non-compliant with their plan care.
  • Introduces new patients to their disease care plan in the Medical home.

Education and Experience

Graduate of an accredited nursing program. BSN or upon hire BSN completion agreement for enrollment in an accredited BSN Completion Program May require specific years of applicable experience to qualify (per department guidelines). If hired prior to 1-1-14 in Winnebago County and prior to 9-1-14 in Rock, Walworth and McHenry Counties an ADN only is required.


Licensed as an RN in the state of practice

Special Physicial Demands

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee must occasionally lift and or move up to 10 pounds.

Culture of Excellence Behavior Expectations

To perform the job successfully, an individual should demonstrate the following behavior expectations:

Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.

Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.

Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.

Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.


<p style="margin: 0px;"><span style="font-size: 12pt;">Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.</span></p>
Share on your newsfeed

Need help finding the right job?

We can recommend jobs specifically for you! Click here to get started.