Care Coordination Specialist

2 weeks ago

Durham North Carolina, United States Avance Care Full time

Position Overview:


Avance Care is dedicated to enhancing the quality of healthcare through innovative primary care solutions.

Our mission is to provide accessible, efficient, and patient-centered healthcare services that prioritize the needs of our patients.

Role Summary:

In this role, you will work closely with the Care Manager, RN, to design, implement, and assess comprehensive care plans for a targeted patient population as they navigate through various stages of care.

Key Responsibilities:

  • Assess patient health status, including medical and social factors, by utilizing data from electronic medical records and collaborating with community healthcare providers.
  • Engage with patients to verify diagnoses, identify contributing factors, and discuss treatment plans, functional capabilities, and barriers to care.
  • Collaborate with interdisciplinary team members to ensure seamless integration of care across the healthcare continuum.
  • Facilitate patient access to necessary services by addressing barriers and advocating for their needs; educate patients and their families on care plans and set realistic, safe goals.
  • Conduct monthly reviews of enrolled patients to ensure treatment objectives are met and that care plans are communicated effectively among care teams.
  • Integrate primary care and specialty services (such as nutrition and behavioral health) to support the achievement of health outcomes and continuity of care.
  • Document all care management activities accurately and ensure resource utilization tracking is precise.
  • Identify patients at risk for high healthcare utilization and coordinate referrals to supportive services or additional caregivers as needed.
  • Maintain comprehensive documentation in electronic medical records and foster collaboration among team members throughout the care continuum.
  • Regularly communicate with integrated team members to ensure continuity of care.
  • Monitor patients with recent emergency room visits or hospital admissions to provide support and reduce readmission risks.
  • Assist with triage assessments and direct patients to appropriate services.
  • Track patient progress throughout their care plans and facilitate warm handoffs to subsequent providers.
  • Demonstrate initiative by proposing process improvements that enhance the delivery of high-quality, cost-effective care.
  • Commit to ongoing professional development, staying informed about regulations, trends in care management, and accountable care organizations.
  • Utilize technology to identify high-risk patients and gaps in care management.
  • Build and maintain strong relationships with internal and external stakeholders.
  • Collect and analyze data as required for various initiatives.
  • Complete all assigned tasks as necessary.
Qualifications:

  • Certification as a Medical Assistant (CMA, CCMA, RMA) or Certified Nursing Assistant (CNA) is required.
  • Fluency in Spanish is mandatory.
  • Experience in case management is preferred.
  • A Bachelor's degree in a healthcare or life sciences field is preferred.
  • 1-3 years of experience in healthcare with direct patient interaction is required.
  • Experience in home health nursing, health coaching, medication administration, or geriatric care is preferred.
Desired Skills:

  • Experience in medical, administrative, or customer service roles.
  • Strong written and verbal communication skills.
  • Familiarity with medical terminology.
  • Understanding of patient confidentiality and HIPAA regulations.
  • Ability to work effectively in a team environment.
  • Proficient computer skills.
  • Attention to detail and strong organizational skills.
  • Effective time management and prioritization abilities.
  • Extensive knowledge of pharmacology.
Work Schedule:

Monday - Friday, 8:30 AM - 5:00 PM
Hybrid work model (1 day remote, 1 day in-person)

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