Care Coordinator

4 weeks ago


Baltimore, Maryland, United States LifeBridge Health Full time
Job Summary

The Community Care Coordinator plays a vital role in promoting the health and well-being of patients by providing face-to-face and phone outreach, as well as email communications. As a member of the Interdisciplinary Team (IDT), this role ensures that patients' individual needs are identified and addressed in a timely manner. The Community Care Coordinator acts as a patient advocate, addressing primary physical and social needs, and linking patients with community resources. This includes assessing and referring patients to community resources, ensuring timely access to services, and respecting patients' rights and wishes.

Key Responsibilities
  • Contact patients, caregivers, and families to ensure preventive services are received
  • Decrease identified care gaps by working with primary care offices to obtain timely appointments
  • Apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators
  • Provide care coordination services for patients requiring chronic care management
  • Ensure patients receive annual physical exams and/or health risk assessments, including completion of required documentation
  • Evaluate and refer patients to the Community Care Manager as appropriate
  • Follow treatment plans as written by providers and/or Community Care Managers
  • Assess patients in their home environment and assist the IDT in evaluating their needs
  • Lead IDT discussions in home management of assigned patients, including facilitation of home care referrals
  • Facilitate discussions with patients and family members on advance directives
  • Link patients with community resources, such as prescription assistance
  • Assist patients in navigating social and health services, including enrollment in social security, Medicaid, Medicare, and other insurance plans
  • Assess and assist patients' safety needs in their home, including fall risk and ordering equipment
  • Assist with self-management of medication, including setting up medication boxes
  • Refer patients or family members to community resources for housing or treatment to assist in recovery from chronic illness
  • Educate and aid family members in understanding, dealing with, and supporting patients with chronic illnesses and end-of-life practices
  • Interview clients about activities of daily living to determine needs and link with community resources
  • Review and update providers and Community Care Managers on patients' living conditions and ability to adhere to plan of care
  • Assess, monitor, and evaluate patients' progress in the home with respect to treatment goals
  • Document findings in healthcare records following System-approved protocols
  • Collect data, maintain records, develop, and utilize assessment and measuring tools relative to patient care and wellness practices
  • Obtain and coordinate access with primary care providers and other specialty providers, including behavioral health
  • Educate patients on availability of resources for primary care and acute care, as well as alternative community programs and services
  • Schedule timely and appropriate office and follow-up visits with healthcare providers
  • Work independently with minimal supervision
  • Participate in community outreach activities as assigned
Requirements
  • Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years acute care and/or ambulatory practice experience
  • Preferably with experience working with care managers from acute care settings or health insurance and/or other payer entities
  • Good verbal and communication skills, as well as organizational skills
  • Competency in electronic medical records desirable
  • Bi-lingual preferable (market-specific)


  • Baltimore, Maryland, United States Always Best Care Senior Service Full time

    Senior Care Coordinator OpportunityAlways Best Care Senior Service is seeking a skilled Senior Care Coordinator to join our team. As a Senior Care Coordinator, you will play a pivotal role in the success of our business by establishing and maintaining contacts that will develop into sales leads.Key Responsibilities:Establish and maintain customer...


  • Baltimore, Maryland, United States Always Best Care Senior Service Full time

    Senior Care CoordinatorAt Always Best Care Senior Service, we're seeking a highly motivated and compassionate Senior Care Coordinator to join our team. As a key member of our care team, you will play a pivotal role in establishing and maintaining relationships with local healthcare providers, families, and community groups. Your primary responsibility will...


  • Baltimore, Maryland, United States Total Health Care (MD) Full time

    Job SummaryTotal Health Care (MD) is seeking a skilled Registered Nurse to join our team. As a Registered Nurse, you will be responsible for providing high-quality patient care through nursing assessment, teaching, and routine nursing procedures. You will work collaboratively with the physician, other healthcare providers, and department support staff to...

  • Care Coordinator

    3 weeks ago


    Baltimore, Maryland, United States University of Maryland Medical System Full time

    Job SummaryCare Coordination and Discharge PlanningThe University of Maryland Medical System seeks a skilled Care Coordinator to provide care coordination and discharge planning for an assigned patient case load. The successful candidate will assess individual patient needs, coordinate and implement plans of care, and monitor and evaluate outcomes across the...

  • Care Coordinator

    4 weeks ago


    Baltimore, Maryland, United States Above it All LLC Full time

    Job OpportunityJob OpportunityAbove It All LLC is seeking part-time professionals to assist clients with entitlements, mental health services, and coordination of care.Key ResponsibilitiesImplement rehabilitation activities outlined in individualized plans with clients.Document encounters with clients, families, and agencies within the company's electronic...


  • Baltimore, Maryland, United States Chase Brexton Health Care Full time

    Job SummaryThe Care Management Specialist delivers and oversees care management services for medically and/or socioeconomically complex patients in accordance with patient-defined goals, multi-disciplinary plan of care, and established policies and procedures.Drawing on best practices in motivational interviewing and care management, the Care Management...

  • Care Coordinator

    4 weeks ago


    Baltimore, Maryland, United States Genesis Healthcare Services Full time

    Genesis HealthCare Services: A Leader in Healthcare ServicesWe are a nation-wide provider of healthcare services, offering a wide range of living options and professional clinical services. Our mission is to deliver high-quality care to our patients and their families.About the RoleAs a Referral Intake Navigator, you will play a critical role in bringing...


  • Baltimore, Maryland, United States Ascension Full time

    Job SummaryWe are seeking a skilled Registered Nurse to join our team at Ascension Saint Agnes in Baltimore, MD. As a Nurse Care Coordinator, you will provide direct nursing care to patients and coordinate with the healthcare team to ensure seamless care delivery.ResponsibilitiesImplement and monitor patient care plans to ensure optimal outcomes.Monitor and...


  • Baltimore, Maryland, United States LifeBridge Health Full time

    Job Summary:The Clinical Care Coordinator will work in a collaborative team model to identify and manage high-risk patient populations, coordinate their care, and provide safe, age-appropriate patient care.Key Responsibilities:Develop and implement patient care plans to ensure seamless transitions and optimal outcomes.Collaborate with healthcare teams to...


  • Baltimore, Maryland, United States Shepherds Clinic Inc Full time

    Job DescriptionAt Shepherds Clinic Inc, we are seeking a highly skilled Nurse Coordinator to oversee patient care and coordinate health care services provided by nursing personnel. The successful candidate will work closely with the Medical Director and be responsible for managing administrative tasks related to grants and reporting.Key...


  • Baltimore, Maryland, United States LifeBridge Health Full time

    RN Care Coordinator OpportunityJob Summary:The RN Care Coordinator will play a vital role in maximizing the health status of patients by collaborating with primary care physicians and specialty services. This position requires frequent communication with patients and caregivers to educate them on health promotion and self-care skills. The RN Care Coordinator...


  • Baltimore, Maryland, United States LifeBridge Health Full time

    Community Care CoordinatorAt LifeBridge Health, we are seeking a skilled Community Care Coordinator to join our team. As a Community Care Coordinator, you will play a vital role in promoting the health and well-being of our patients by providing face-to-face and phone outreach, as well as email communications.Key Responsibilities:Develop and implement care...


  • Baltimore, Maryland, United States LifeBridge Health Full time

    RN Care Coordinator RoleAt LifeBridge Health, we are seeking a skilled RN Care Coordinator to join our team. As a RN Care Coordinator, you will work closely with primary care physicians and specialty physicians to maximize patient health status. This role requires frequent contact with patients and their caregivers for education on health promotion and...

  • RN Care Coordinator

    3 weeks ago


    Baltimore, Maryland, United States LifeBridge Health Full time

    RN Care Coordinator Job SummaryThe RN Care Coordinator will play a vital role in maximizing the health status of patients by working closely with primary care physicians and various specialty physicians and services. This position requires frequent contact with patients and their caregivers to educate them on health promotion and self-care skills.The RN Care...


  • Baltimore, Maryland, United States University of Maryland Faculty Physicians Full time

    Job SummaryAs a Medical Matron at the University of Maryland Faculty Physicians, you will play a vital role in facilitating effective communication between the healthcare team, patients, and their families. Your primary responsibility will be to coordinate care and ensure quality, safe, and effective patient outcomes.Key ResponsibilitiesCoordinate care to...


  • Baltimore, Maryland, United States LifeBridge Health Full time

    Job Summary:As a Nurse Navigator at LifeBridge Health, you will play a critical role in identifying and managing high-risk patient populations, coordinating their care, and providing safe, age-appropriate patient care. This is a collaborative team model that requires strong communication and interpersonal skills.Key Responsibilities:Identify and manage...


  • Baltimore, Maryland, United States Chase Brexton Health Care Full time

    Job Summary:The Population Health Pre-Visit Planner plays a vital role in the multidisciplinary healthcare team at Chase Brexton Health Care. This position is responsible for data collection, closing gaps in care, and coordinating care for patients under the supervision of the Population Health Lead Pre-Visit Planner.Key Responsibilities:Complete pre-visit...


  • Baltimore, Maryland, United States Chase Brexton Health Care Full time

    Job Summary:The Population Health Pre-Visit Planner plays a vital role in the multidisciplinary healthcare team at Chase Brexton Health Care. This position is focused on data collection, closing gaps in care, and assisting in the coordination of care for patients under the supervision of the Population Health Lead Pre-Visit Planner. The successful candidate...


  • Baltimore, Maryland, United States LifeBridge Health Full time

    Clinical Excellence at LifeBridge Health **Job Summary:** As a Nurse Navigator at LifeBridge Health, you will play a vital role in identifying and managing high-risk patient populations, coordinating their care, and providing safe, age-appropriate patient care. **Key Responsibilities:** * Collaborate with a multidisciplinary team to develop and implement...


  • Baltimore, Maryland, United States LifeBridge Health Full time

    Job Summary:We are seeking a skilled Nurse Navigator to join our team at LifeBridge Health. As a Nurse Navigator, you will play a critical role in identifying and managing high-risk patient populations, coordinating their care, and providing safe, age-appropriate patient care.Key Responsibilities:Collaborate with a multidisciplinary team to develop and...