Patient Care Coordinator I

2 weeks ago

West Bloomfield Township, Michigan, United States IHA Full time

Hybrid Work Opportunity: Potential for remote work options following the training phase.

Position Overview:

The Patient Care Coordinator I plays a vital role within the patient care team. This position is responsible for managing and coordinating care for patients experiencing transitions in their health status, undergoing treatment, or dealing with moderate to complex health issues, all while operating with minimal oversight.

Key Responsibilities:

  • Collaborates with healthcare professionals and patients to deliver high-quality, efficient, and patient-centered healthcare services.
  • Supports patients at risk of chronic conditions by providing education and self-management resources, empowering them to take charge of their health.
  • Implements targeted strategies to prevent hospitalizations and emergency visits, ensuring appropriate care delivery in line with established protocols.
  • Conducts assessments, plans, implements, monitors, and evaluates personalized patient care aimed at optimizing health outcomes.
  • Actively participates in the office-based care team, aiding in the identification and referral of patients who qualify for care management services.
  • Engages with hospitalized patients to facilitate their transition of care and provide necessary support and education to prevent readmissions.
  • Coordinates care across various member populations, ensuring effective use of healthcare resources while collaborating with the healthcare team to achieve optimal clinical outcomes.
  • Utilizes established guidelines for managing chronic diseases effectively.
  • Conducts outreach to engage patients in the program, including making initial contact.
  • Identifies and prioritizes interventions for common and complex patient populations, designing individualized care plans based on evidence-based practices.
  • Collaborates with other care team members to ensure comprehensive service coordination.
  • Provides feedback to healthcare providers and the clinical team regarding patient-specific needs.
  • Maintains proficiency in relevant computer systems, including electronic medical records and care management tools.
  • Customizes services to meet patient needs while working within their insurance benefits.
  • Researches and connects patients with community resources when services fall outside their benefits.
  • Participates in the orientation of new care managers by providing shadowing opportunities.
  • Adjusts daily workflows to enhance efficiency and effectiveness.
  • Attends mandatory meetings and training sessions; contributes to committees as needed.
  • Assists with special projects and performs additional duties as required within the scope of RN licensure.

Specialized Team Functions:

Home-Based Care Team:

  • Evaluates home and social determinants of health for patients aged 65 and older.
  • Works with the Home-Based Nurse Practitioner and/or primary care physician to implement coordinated care plans that align with patient goals and preferences.

Behavioral Health Team:

  • Provides support to high-acuity patients at risk for chronic conditions through education and self-management resources.
  • Utilizes guidelines for managing behavioral health needs effectively.
  • Assesses behavioral health risks and formulates action plans for patients.

Organizational Expectations:

  • Fosters a positive, professional work environment that aligns with the mission and values of IHA.
  • Collaborates effectively as part of the clinical team.
  • Ensures job duties are performed safely and responsibly, reporting any hazards immediately.
  • Completes all required training and adheres to IHA standards of care.
  • Maintains knowledge of organizational policies and procedures.
  • Upholds confidentiality in compliance with HIPAA regulations.
  • Demonstrates a commitment to professional development and maintains relevant licensure and certifications.

Qualifications:

Education: Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing with substantial experience.

Licensure: Valid RN license in Michigan; CPR certification required. CCM/CCP certification preferred.

Experience: 3-5 years in primary care, home health, behavioral health, or related fields preferred.

Skills: Strong knowledge of patient care procedures, chronic conditions, and excellent communication abilities.

Physical and Environmental Expectations:

  • Ability to perform physical tasks related to patient care and office duties.
  • Work environment includes exposure to medical equipment and potential hazards.

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