Care Coordination Specialist
7 days ago
**Job Summary**
Springfield Medical Care Systems, Inc. is seeking a highly skilled Clinical Care Coordinator to join our team at our Springfield Health Center. As a Clinical Care Coordinator, you will play a pivotal role in engaging individuals seeking to prevent and manage chronic conditions, identifying their priorities for their care, developing a care plan, and coordinating its implementation in partnership with the patient, their care team, and community partners.
Key Responsibilities:
- Promote and work to achieve our mission and vision of delivering high-quality, patient-centered care to our community.
- Assess patients' clinical, social, functional, and continuing care needs to identify their priorities and desired outcomes for their treatment.
- In consultation with the patient, their care team, and related partners, develop a care plan including immediate, short-term, and long-term goals reflecting patients' priorities and time frames to achieve desired outcomes.
- Demonstrate knowledge and understanding of the client's diagnosis, prognosis, care needs, as well as cost and barriers to goal achievement.
- Assist in transition of care through patient outreach, communication with relevant service providers following discharge from other care settings to ensure a smooth transition to outpatient care, with the goal of decreasing readmissions.
- Communicate with patients and families in an effective, patient-centered manner; coordinate with other team members to provide exceptional patient service.
- Maintain positive working relationships and demonstrate exceptional customer service skills. Work cooperatively, address conflict, and communicate effectively with all providers, team members, patients, and their families.
- Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support.
- Provide Chronic Care Management services as appropriate to eligible patients.
- Ensure effective tracking of test results, medication management, and adherence to follow-up appointments.
- Support patient self-management of disease and behavior modification interventions.
- Proactively outreach to selected patients, perform home visits as necessary for assessment and engagement.
- Participate in quality improvement activities, collecting and analyzing data.
Requirements:
- Experience with Care Planning.
- Two (2) year's nursing experience.
- Excellent communication skills.
- Proficiency with Microsoft Office, computer skills.
- Current LPN License.
- One (1) – Two (2) years' experience in case management (preferred).
- Current RN License (preferred).
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