Care Coordinator

Job Purpose: Work under the direction of the Care Manager, RN, to establish, implement, monitor, and evaluate high quality, cost-effective care plans as patients move across the care continuum for a designed population.

Essential Duties and Responsibilities

• Review of the patient’s health status, medical and social, utilizing data from the electronic medical record claims, and additional resources shared with community providers
• Outreach to patients to confirm diagnosis, contributing factors, anticipated treatment plan, current and projected functional ability, and barriers to care
• Act as an extension of the primary care practice by partnering and collaborating with interdisciplinary team members across the continuum of care
• Facilitate access to necessary care by navigating barriers and advocating for the patient; educate patients and families/caregivers on the plan of care, the barriers to that care, and set expectations while setting achievable, safe goals
• Review patients enrolled in care management each month to ensure treatment goals are met and the care plan is shared across the care teams, utilizing care coordinators as necessary
• Integrates the primary care team and Specialty Services (i.e. nutrition, behavioral health, medication therapy management), as applicable to support the achievement of health outcome goals with continuity of care
• Evaluate, coordinate, manage, and document all activities related to care management and ensure tracking of resource utilization and time is accurate
• Identify patients who are at risk for high utilization and determine possible supportive services, programs, or additional caregivers that could assist in reducing this risk and coordinate needed referrals or outreach, utilizing the referral department and care coordinators as necessary, to provide access to these additional supportive services
• Complete all required documentation in the electronic medical record; making team members aware/collaborating throughout the continuum of care
• Communicate regularly with integrated team members
• Track patients who have had a recent ER visit, hospital admission, or inpatient procedure and reach out to provide support, maintain continuity of care between hospital and PCP, and reduce risk for readmission
• Assist with primary care provider triage assessment and direct patient to appropriate services
• Track patients throughout their care plan and perform a warm handoff to the appropriate next provider to care in the interval between primary care visits and care plan updates
• Demonstrate initiative and creativity by identifying modifications in processes and workflows that will improve our ability to deliver cost effective, high quality care
• Assume accountability for professional growth and development, including a working knowledge of regulations/initiatives, trends in ambulatory and cross continuum care management, and accountable care organizations
• Utilize information technology systems to identify high risk patients, contributing factors of risk and gaps in preventative and chronic care management
• Develop and maintain a sound working relationship with internal and external stakeholders
• Collect data as needed within initiatives for ongoing analysis

Qualifications
Education, Experience and Licensure:

• Holds one of the following:
• Certified Medical Assistant (CMA, CCMA, RMA)
• Certified Nursing Assistant (CNA)
• Licensed Practical Nurse (LPN)

• Case management experience, preferred
• Bachelor’s degree in healthcare of life-science related field, preferred
• At least 1-3 years of healthcare experience with direct patient care
• Experience with home health nursing, health coaching/education, medication administration, and/or care for geriatric populations, preferred

Job Type: Full-time