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Care Coordinator

2 months ago

Brockton, Massachusetts, United States Harbor Health Services Full time
About the Role

Harbor Health Services is seeking a skilled Care Coordinator to join our Elder Service Plan team. As a Care Coordinator, you will play a vital role in supporting the Interdisciplinary Team (IDT) in delivering high-quality patient care.

Key Responsibilities
  • Collaborate with the Utilization Management RN to coordinate patient admissions and discharges, ensuring seamless transitions and effective communication with the IDT.
  • Coordinate participant admissions and discharges to/from short-term rehab or long-term care, including referrals, transportation, and necessary paperwork.
  • Ensure specialty appointments have proper referral and authorization documentation, and coordinate follow-up studies and appointments.
  • Document all outside encounters, including ED, hospitalization, and nursing care, to support accurate fiscal performance analysis.
  • Ensure all participants receive Care Plans and associated assessments every six months, utilizing reports and Electronic Health Record investigation to ensure CMS compliance.
  • Prepare for and facilitate morning IDT meetings, including chart review, external record review, and histories, service delivery requests, long-term care tools, and special team projects.
  • Tightly manage follow-up action items from meetings to ensure critical tasks are completed in a timely manner.
  • In collaboration with the IDT, ensure a seamless new participant experience by coordinating multiple services for the first day in the program, ensuring critical tasks are completed for patient safety and satisfaction.
  • Facilitate critical clinical meetings involving the IDT, outside facilities, vendors, and patients/caregivers, often requiring complex decision-making and conflicting opinions.
  • Communicate with Home Care Manager and Rehab Manager regarding support services as needed.
  • Coordinate multiple treatment providers for participants with multiple comorbidities and complex care needs.
  • Serve as the point of contact for the IDT, participants, families/caregivers, nursing facilities, and outside vendors.
  • Serve as the point person for the IDT when out in the field, needing troubleshooting and/or information sharing between team members, serving as an intermediary between participants and clinicians, call screener, and communicating detailed information to clinicians.
Requirements
  • HS Diploma or GED, Bachelor's Degree in healthcare or related field
  • May substitute clinical certification (CNA or Medical Assistant) with 4 years of related experience or Associates' Degree in healthcare or related field with 2 years of experience, for the Bachelor's degree
  • One year of experience working in a healthcare environment performing care coordination, case management, medical office management, or other related duties
  • Experience working with an elderly population preferred
  • Intermediate skill level with Microsoft Office 365, including Word, Outlook, Excel, and Microsoft Teams
  • Proven ability to resolve problems creatively
  • Excellent verbal and written communication and organizational skills
  • Ability to work independently and as a member of a team
  • Adept at time management, excellent multi-tasking skills, experience working with competing priorities, fielding and follow-up of phone calls while maintaining focus throughout the day
  • Ability to be flexible and creative as the role grows and adapt to new changes
  • Must be able to utilize critical thinking skills independently to problem-solve complex situations