Care Coordinator
4 weeks ago
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
- 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)
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