The Care Coordinator is responsible for managing the care of the patient population by developing pathways towards expected patient outcomes, defining appropriate resource utilization, providing proper education, and working in conjunction with the provider to set achievable goals for the patient.
Assists all patients through the healthcare system by acting as a patient advocate and navigator. Assists patients with understanding their medical diagnoses, treatment options, and achieving best outcomes. Coordinates continuity of patient care with external healthcare organizations and facilities, including the process of hospital admission, discharge, and referrals from the primary care provider to a specialty care provider.
Manages high risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting. Facilitates patient education regarding health, disease, medications, and lifestyle modifications. Supports patient self-management of disease and behavior modification interventions.
Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed. Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans and evaluating outcomes. Communicates emergent information to the clinician when issues arise between visits.
Facilitates patient medication management based upon standing orders and protocols. Evaluates clinical care, utilization of resources, and development of new clinical tools, forms, and procedures. Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered Medical Home and quality improvement initiatives.
Maintains a professional appearance and a clean, safe environment. Respects patients by recognizing their rights; maintaining confidentiality. Utilizes technology, including specialized software as applicable, to maximize productivity.
Develops and maintains electronic files as necessary. Exhibits excellent interpersonal skills; provides customer service; assists other support staff as necessary; collaborates with all levels of internal leadership, management, and staff as well as outside clients, vendors, and other external parties. Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, and participating in professional societies.
Other duties as assigned. Qualifications/Requirements:
Two (2) to five (5) years of previous clinical, care coordination, and/or case/disease management experience preferred. Experience with and/or extensive knowledge of Patient Centered Medical Home (PCMH) initiatives.
High school diploma or equivalent required. Four-year degree from an accredited institution preferred. Licenses /
Other: Bilingual (English/Spanish) candidates preferred, but not required. Proficiency in Microsoft Office (Outlook, Word, Excel, and Power Point). Special
Physical
Physical Activity (please check one box): ☐ Sedentary Work (involves sitting most of the time, occasionally walking and standing; requires lifting no more than 10 pounds at a time and/or occasionally lifting or carrying objects) ☐ Light Work (involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds; requires moderate mobility to different work locations) ☐ Medium Work (involves substantial physical activity and mobility; and lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25 pounds.) ☐ Heavy Work (involves some type of manual labor including operating heavy machinery/ equipment or physical labor; requires lifting no more than 100 pounds at a time with frequent lifting or carrying of objects weighing up to 50 pounds)