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Care Coordinator

4 months ago

Excelsior Springs, United States Excelsior Springs City Hospital Full time

Coordinate care between ESH Primary care providers, specialists, and Psychiatric providers.Collaborate, communicate, coordinate with patients, families, caregivers, community outreach (schools, social workers), and staff at other facilities regarding plan, and for continuity of care.Assist in Psychiatric integration into medical specialties (CoCM: Collaborative Care model): (On-site care coordination, extended office hours as needed, work with the patient and family to access community resources, same-day appointments, easy access to new, established/follow-up, and crisis patients, team-based care: team members working to the top of their scope, license, training, collaboration with other medical providers, patient engagement in self-management of chronic diseases, measuring metrics to improve care and decrease cost, following core principles of CoCM, focus on, and provide patient education on Psychiatric and Medical comorbidities, chronic disease management, Biopsychosocial/Harm-reduction models)Verify Psychiatric insurance coverage for patients and families.Work with insurance companies, with assistance from ESHs team/s, to find resources, obtain out-of-network authorizations, assist with sliding scale, financial assistance/aide.Schedule/reschedule appointments, manage schedules including crisis evaluations, follow-ups including ED/hospitalization, same-day visits arising from calls or crisis referrals.Rooming patients for their scheduled or crisis visits, medication-administration, injections, screening, vitals, Psychotherapy/Counseling/Group therapyAnswer phone calls, respond to emails, EHR inbox messages promptly.Triage calls/patients based on acuity, respond promptly including gathering any required collateral information from families, other sources, and communicate with respective provider/sAssist with calls re Medication refills, questions about medications, Prior AuthorizationsAssess/Evaluate patients, develop initial individualized plans of care, collaborate with respective provider, and determine appropriate services, referrals using principles of Biopsychosocial model and Harm-reduction model.Maintain patient records, reports, registry/caseload, monitoring progress or worsening.Review medications including current and expired prescriptions Confirm correct name, dose, frequency for all medications, at every visit during rooming Reconcile medications after hospital discharge, transfer of care, scan list/s Compare the discharge list to the current medication list in EHR.Assist with ordering, reviewing basic Labs including CBC, CMP, UDS, HbA1c, Fasting Lipid PanelEnsure documentation/forms are filled, signed, verified, including: Demographics, Cover Letter, Fax Transmittal Sheet, Patient Information Update, Medical history and record requests, Consent to release records (Release of Information), Medication Record, and Billing FormsProvide Psychoeducation, Motivational interviewing, Supportive therapy including Smoking cessation information, education, Healthy Lifestyle including Sleep hygiene, eating habits, activities, Mental Health, Wellness, and Wellbeing education.Assist in the role of suicide watch in ER/ED in time of need, sharing the goals of providing care, filling in the role of aiding hospital staff with acute mental health/illness needs.Performs other duties and responsibilities as assigned.