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Patient Care Coordinator
2 months ago
Salary:
$70,000 - $90,000 / Annually
Overview:
The Patient Care Coordinator (PCC) is responsible for executing thorough patient evaluations to oversee healthcare requirements throughout the care spectrum.
This position is designed to improve individual health and self-management capabilities through a collaborative team approach, which includes behavioral health specialists and community health workers.
Key responsibilities encompass conducting in-person consultations for members who necessitate such engagements and evaluations.The objective is to organize and facilitate services that align with member needs, adhering to benefit frameworks and accessible community resources.
The PCC, in conjunction with the interdisciplinary team, will formulate patient care strategies in partnership with the patient, ensuring cost-effective and high-quality results centered on the outpatient environment.
Situated within healthcare provider facilities, the PCC collaborates closely with providers, office personnel, care management teams, and community partners to oversee member care.
This role will uphold the mission, vision, and values of Community Health Program Inc and comply with regulatory standards as well as organizational policies and procedures.
Essential Duties and Responsibilities of the Patient Care Coordinator:Manages and oversees a designated panel of members.
May perform in-person visits for onboarding new members and reassessing existing members, employing various interviewing techniques to:
evaluate a member's clinical and functional status to identify ongoing special conditions and
create and execute a personalized, coordinated care plan, in collaboration with the member, clinical team, primary care providers, specialists, and other community partners, to ensure a cost-effective quality outcome.
Conducts medication reconciliations.
Implements Transitional Care Management (TCM) in accordance with program and product line protocols.
Stays updated on program and product line benefits, Plan Handbook specifics, and departmental policies. Adheres to established procedures to educate members and providers, advocating for member rights and providing necessary information.
Advocates for members to guarantee they receive appropriate benefits.
If member needs are identified and they are not eligible for coverage, collaborates with community organizations to connect members with additional services, such as transportation, food assistance, and senior center resources, when needs are not covered by the organization.
Adheres to departmental and regulatory standards to authorize and coordinate healthcare services, ensuring timely compliance with documented care plan objectives.
Evaluates the member's understanding of their current disease management and medication regimen, providing education to enhance member/caregiver knowledge, and assists members in learning how to self-manage their health, social, or behavioral health needs.
Collaborates with relevant team members to ensure health education and disease management information is provided as necessary.
Works with the interdisciplinary team to identify and address rising and high-risk members.
Educates members on preventive screenings and other healthcare procedures such as vaccinations and screenings according to established protocols and program processes.
Ensures members and their representatives participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team.
Strictly adheres to HIPAA regulations and organizational policies regarding the confidentiality of member information.
Supports Quality and Ad-Hoc initiatives.
Provides culturally competent care coordination, i.e., collaborates with interpreters, supplies communication-approved documents in the appropriate language, and demonstrates culturally sensitive behavior when interacting with members, families, caregivers, and/or authorized representatives.
In collaboration with the member and their representatives, develops member-centered care plans by identifying care needs while completing program assessments and working with the member to approve their care plan.
Monitors the progress of member goals and care plan objectives, providing feedback and collaborating with care team members to effectively coordinate a continuum of care aligned with the member's healthcare goals and needs.
Establishes and maintains relationships with members, families, caregivers, representatives, vendors, and providers to ensure optimal collaboration and coordination of healthcare needs, promoting timely, cost-effective, and high-quality care.
Actively engages in clinical rounds.
May coordinate and/or attend in-person member/provider visits, care plan meetings with providers and office staff, and may lead care plan reviews with providers and care teams as applicable.
Demonstrates exemplary customer service actions and takes responsibility to ensure member and provider requests and needs are addressed.
Performs additional responsibilities as assigned by the Manager or designee.
Supports departmental colleagues, covering and adapting to changes in assignments as directed by the Manager or designee.
Identifies high-risk patients by reviewing monthly risk stratification data.
Competencies:
To perform the job successfully, an individual should demonstrate the following competencies:
Excellent communication and interpersonal skills with members and providers via telephone and in person.
Exceptional customer service skills and a commitment to ensuring timely resolutions.
Strong organizational skills and the ability to manage multiple tasks.
Appreciation and adherence to policy and process requirements.
Independent learning skills and success with various learning methodologies.
Willingness to learn about insurance regulatory and accreditation requirements.
Proficient in software systems including but not limited to Microsoft Office Products - Excel, Outlook, and Word.
Familiarity with Excel spreadsheets to manage work and exposure, including pivot tables.
Accurate and timely data entry.
Effective case management and care coordination skills, with the ability to assess a member's daily functioning and develop and implement a care plan that meets the member's needs.
Knowledge of community resources, levels of care, criteria for levels of care, and the ability to appropriately develop and implement a care plan following regulatory guidelines and level of care criteria.
Essential Skills and Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Experience:
2+ years of clinical experience as a Registered Nurse working with diverse age groups.
Experience working with individuals on MassHealth coverage who may face social, economic, and/or complex medical and behavioral health challenges is preferred.
Understanding of hospitalization experiences and the associated needs following facility discharge is required.
Ability to communicate and collaborate with primary care providers, community partners, and ACOs to manage member care is essential.
Experience with telephonic interviewing skills and working with a diverse population, including non-English speakers, is required.
Home Health Care experience is preferred.
Experience in a community social service agency, skilled home health care agency, or relevant state agency (e.g., Department of Mental Health, Department of Developmental Services, Department of Children and Families, or Department of Youth Services) is preferred.
Experience working face-to-face with members and providers is preferred.
Demonstrated ability to perform independently as a clinician with minimal supervision or assistance.
Experience with self-scheduling of caseload is preferred.
Education and Training:
Registered Nurse licensure is required.
Bachelor's (or advanced) degree in nursing or a healthcare-related field is preferred.
Graduate of a N.L.N. accredited nursing program.
CPR certification is required every two years.
License, Certification & Registration:
RN - License as a professional nurse within the state.
Active and valid driver's license.
Full-Time/Part-Time
Full-Time
Position
Pediatric Population Health Nurse
Exempt/Non-Exempt
Exempt
EOE Statement
We are an equal employment opportunity employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.
