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Care Coordinator

3 months ago


Georgetown, United States La Red Health Center Inc Full time
Job DescriptionJob DescriptionDescription:

Supervisory Report: Director of Quality

Wage Classification: Non-Exempt

Job Summary:

The Care Coordinator works in collaboration and continues partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/ specialty providers and staff, and community resources in a team approach to:

  • Promote timely access to appropriate care.
  • Increase utilization of preventive care.
  • Reduce emergency room utilization and hospital readmission.
  • Facilitates health and disease patient education.
  • Increase comprehension through culturally and linguistically appropriate education.
  • Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s).
  • Supports patient self-management of disease and behavior modification intervention.
  • Facilities patient medication management based upon standing orders and protocols.
  • Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
Requirements:

Essential Responsibilities:

  • Serve as the contact point, advocate, and information resource for patients, care team, family/caregiver(s), and community resources.
  • Work with patients to plan and monitor care:
  • Assess patient’s unmet health and social needs.
  • Develop a care plan with the patients, family/caregiver(s) and provide (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).
  • Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.
  • Create ongoing process for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time.
  • Facilitate patient’s access to appropriate medical and specialty providers.
  • Educate patient and family/caregiver(s) about relevant community resources.
  • Facilitate and attend meetings between patients, family/caregiver(s), care team, payers, and community resources, as needed.
  • Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
  • Attend all Care Coordinator training courses/webinars and meeting.
  • Provide feedback for the improvement of the Care Coordination Program.