Clinical Care Coordinator
3 weeks ago
The Clinical Care Coordinator will collaborate with at-risk population patients and their primary care providers to provide care that ensures the delivery of quality, efficient, and cost-effective healthcare services.
Key Responsibilities- Assess, plan, implement, coordinate, monitor and evaluate all options and services with the goal of optimizing the at-risk population patient's health status.
- Identify the at-risk population patients within the practice site and risk stratify all patients to prioritize needs and direct interventions.
- Collaborate with primary care providers to enhance evidence-based clinical guideline adherence and promote best practice by initiating/adjusting therapies as directed by the practitioner and providing appropriate follow-up and monitoring as needed.
- Design an individualized care plan with the client and foster a team approach to working collaboratively with the patient, family, primary care provider, and other members of the healthcare team to ensure coordination of services.
- Continuously evaluate laboratory results, diagnostic tests, utilization patterns and other metrics to monitor quality and efficiency results for the assigned population.
- Coordinate appropriate laboratory and diagnostic testing.
- Manage utilization and practice metrics to further refine the delivery of care model to maximize clinical, quality, and fiscal outcomes for the at-risk population.
- Implement clinical interventions based on risk stratification and evidence-based clinical guidelines.
- Develop and implement systems of care that facilitate close monitoring and promote early intervention in acute care situations for patients in this at-risk population.
- Review the current literature regarding effective engagement and communication strategies, case management strategies, and behavior change strategies and incorporate into clinical practice.
- Coordinate referrals and other community resources.
- Work with the quality team to design, implement, evaluate and improve the Healthy Medical Home care delivery model.
- Collect required data and utilize data to adjust the treatment plan when indicated.
- Maintain required documentation for all case management activities.
- Adhere to HIPAA guidelines.
- Assist other team members to ensure even distribution of workload and shares in assigned tasks.
- Incorporate excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills into case management practice.
- Comply with the Springfield Clinic incident reporting policy and procedures.
- Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
- Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
- Perform other job duties as assigned.
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