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Care Coordinator

2 months ago

Providence, Rhode Island, United States Lifespan Full time

Job Summary:

Lifespan is seeking a skilled Care Navigator to support our Nurse Care Management department in caring for rising-risk and high-risk patients. As a key member of our team, you will play a vital role in obtaining information about patients with medical and social needs, and act as a resource to assist patients in navigating the healthcare system.

Key Responsibilities:

  • Screen patient census using provided criteria to determine if the patient should be categorized as high risk
  • Manage the high-risk patient census to assess if intervention from the Nurse Care Manager (NCM) or other disease management/population health program is needed
  • Assess patients for basic needs and intervene when appropriate, referring patients with greater needs to the NCM for intervention
  • Work closely with the NCM to help patients reach their goals, maintain safety, and improve their health
  • Have awareness and understanding of community and Coastal resources/teams to offer patients
  • Hand off communication to the NCM or other Coastal program when necessary
  • Work with the NCM to develop and update patient care plans and attend care conferences and huddles as needed
  • Perform telephonic and remote patient outreach to patients, documenting all outreach and interventions in the electronic medical record (EMR)
  • Facilitate and reinforce patient self-management under the direction of the NCM and encourage patients to keep up to date with labs, PCP, and specialist visits, and their care plan
  • Evaluate for patient safety
  • Ensure documentation is collected from patient specialist visits
  • Provide resources and disease management education to patients
  • Be comfortable with MOLST and durable power of attorney forms to lightly discuss with patients
  • Understand durable medical equipment (DME) needs and referrals
  • Have in-depth understanding of medical insurances and benefits
  • Assist patients with transportation needs
  • Perform other job-related duties as assigned

Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, ethnicity, sexual orientation, ancestry, genetics, gender identity, or expression, disability, protected veteran, or marital status. Lifespan is a VEVRAA Federal Contractor.