Location:
Lac du Flambeau, WI Exit Disclaimer: You Are Leaving www.ihs.gov
Type: Tribal Salary Range: Salary Negotiable Open Period: 7/7/2026 until filled Summary: For further information and how to apply, contact directly: Human Resources Department P.O. Box 67 Lac du Flambeau, WI 54538 715-588-3303 Email: hr@ldftribe.com
The primary responsibility of this position is to work with multidisciplinary healthcare teams in a primary care setting with the focus on coaching and coordination of care for designated high-risk patients while working along side primary care providers, care teams, and office staff in a PCMH, focusing on identifying the needs of complex patients while assisting the practice to develop a process for managing its patient population. Job Announcement Flyer: PCMH Care Coordinator JUL26.pdf [pdf - 213.29 KB] Duties: Registered Nurse with appropriate past experience in a Patient-Centered Medical Home environment and case management preferred. Associate Degree from an accredited Nursing program required; Bachelor''s Degree preferred. Must hold a current Wisconsin Registered Nursing License with no restrictions or violations with the Wisconsin Nursing Board; compact license without violations or restrictions accepted. Hold current BLS and ACLS certification or ability to obtain and maintain certification within 6 months of employment. PALS certification preferred. Qualifications: Responsible for assessing, coordinating and integrating healthcare for patients/families with chronic conditions across the life span in the Patient- Centered Medical Home (PCMH). The Patient-Centered Medical Home Care Coordinator will facilitate the provision of comprehensive health promotion and chronic condition care; as well as promote a focus of ongoing, proactive and planned care. The PCMH Care Coordinator uses effective communication strategies among family, the medical home, schools, specialists and community professionals and community connections to help improve, measure, monitor and sustain quality outcomes (clinical, functional, satisfaction and cost containment). This position will require covering for nursing staff in the clinical area as needed. Specific responsibilities include but are not limited to the following: 1. Demonstrate and apply knowledge of the philosophy/principles of comprehensive community based, patient/family-centered, developmentally appropriate, culturally sensitive care coordination services. 2. Collaboratively establish with clinical leadership measurable goals to increase patient access, address current care opportunities and reduce adverse events by analyzing and reporting measurable progress against goals. 3. Implement process improvements to assist the organization in becoming a Patient-Centered Medical Home. 4. As a collaborating member of the health care team, provides pre-visit and follow-up direction and support to the patient/family and health care providers. 5. Assist with the identification of patients in the practice with special health care needs, create/maintain patient registry to be used for planning and monitoring care and outcomes. 6. Build care relationships among patient/family and the care team. 7. Carry out care plans, evaluate effectiveness, monitor in a timely way and effect changes as needed. 8. Serve as a point of contact, advocate and informational resources for the patient/family and community partners/payers. 9. Research, find and link resources, services and supports with/for the patient/family. 10. Critically evaluates patient cases through reviews of treatment plans and medical records. Work Type: Permanent, Full Announcement #: Patient-Centered Medical Home Care Coordinator-RN Who May Apply? US Citizens