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Chronic Illness Care Coordinator
2 months ago
POSITION OVERVIEW
The Chronic Illness Care Coordinator is responsible for delivering education and case management services to individuals managing chronic diseases, including those living with HIV. This role collaborates closely with the Clinical Director of Coordinated Care, the Director and Assistant Director of Remote Care Management, the HIV Medical Director, and the Positive Connections Program Coordinator, operating under the general guidance of the Chief Medical Officer and/or Primary Care Providers. The Chronic Illness Care Coordinator will facilitate the enrollment of referred patients into Remote Care Services, which encompass Chronic Care Management and Remote Patient Monitoring. Services are rendered through various modalities such as telehealth, secure messaging, or face-to-face interactions. This position also extends to providing case management support for HIV-positive clients. The coordinator will ensure that all necessary documentation, screenings, and educational materials are up-to-date and completed promptly. Continuous monitoring, evaluation, documentation, follow-up, and collaboration with the patient's care team are essential components of this role. This position requires effective interaction with Federal, State, and local agencies to optimize resources and achieve program development objectives.
KEY RESPONSIBILITIES
Reasonable Accommodations Statement
To successfully perform this role, an individual must be able to complete each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform essential functions.
Core Responsibilities
- Develop a comprehensive Medical Services Plan for clients receiving ongoing Chronic Illness Case Management within thirty (30) days of enrollment, adhering to the standards and assessment forms mandated by relevant health authorities.
- Review and update Medical Services Plans for all active clients based on their acuity levels, following established guidelines.
- Engage in case conferencing with the client's medical service provider at least every six (6) months or as dictated by acuity levels.
- Facilitate the transfer and inactivation of clients in accordance with health policies.
- Document client interactions in progress notes, required forms, and the designated database.
- Provide referrals for medical evaluations and treatments as necessary.
- Manage case consultations with a variety of healthcare professionals, including physicians, nurses, and service access specialists.
- Oversee case management related to HIV medication therapy, including educating clients about side effects and monitoring adherence.
- Coordinate medical care and disease management activities effectively.
- Deliver educational sessions to nursing staff as appropriate.
- Provide information on HIV, its transmission, complications, and risk reduction strategies.
- Conduct assessments and interventions related to adherence, nutrition, and other health-related issues.
- Support team members in delivering medical services to clients affected by HIV.
- Participate in outreach events organized by the Community Health team as needed.
- Engage in quality improvement initiatives and adhere to applicable standards.
- Maintain up-to-date knowledge of immunization protocols as outlined by health authorities.
- Promote patient-centered care that respects cultural and linguistic diversity.
- Educate clients about health maintenance, healthy behaviors, and community support services.
- Utilize health information systems effectively to enhance care delivery.
- Participate in care team meetings to coordinate patient care activities.
- Incorporate quality indicators into patient care plans.
- Perform additional duties as assigned.
Competency Statements
- Accountability - Ability to accept responsibility for actions.
- Active Listening - Skill in understanding and addressing the comments and questions of others.
- Adaptability - Capacity to adjust to changes in the workplace.
- Analytical Skills - Proficiency in using reasoning to solve problems.
- Communication Skills - Ability to convey information effectively, both orally and in writing.
- Detail Orientation - Attention to minute details in tasks.
- Team Collaboration - Ability to work effectively with diverse personalities.
- Time Management - Skill in organizing and completing work within deadlines.
Education: Associate's Degree in a related field; High School Diploma or GED required.
Experience: Minimum of one year of experience in a healthcare setting.
Skills: Proficiency in Microsoft Word and Excel; familiarity with electronic record-keeping systems.
Licenses: Current LPN license in the relevant state required. CPR and TB certifications required upon hire and annually thereafter.
Other Requirements: Ability to relate effectively to the public and communicate with internal and external stakeholders. Willingness to pursue continuing education related to this role.