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Care Coordination Specialist

2 months ago

Irving, Texas, United States Christus Health Full time

Role Overview: The Care Coordination Specialist operates under the guidance of the Population Health Director of Care Management or Nurse Manager, delivering patient care through established physician-approved protocols and best practice standards.

Key Responsibilities:

  • Enhance communication among patients, caregivers, physicians, and the outpatient care team to promote health, minimize hospital admissions, and improve patient stability.
  • Collaborate with Nurse Navigators to ensure medical stability for patients with complex health issues and multiple comorbidities.
  • Manage a substantial case load of 10,000-15,000 patients, identifying and addressing care gaps in partnership with the Health Care Team.
  • Engage with the Patient-Centered Medical Home (PCMH) Team to design, implement, and assess the PMH model as needed.
  • Proactively coordinate preventive and follow-up care for all patients receiving services from participating providers.
  • Review patient medical records to pinpoint care deficiencies and schedule necessary preventive services based on evidence-based protocols.
  • Foster a collaborative environment by working closely with patients, families, primary care providers, and other healthcare team members to ensure seamless service coordination.
  • Assist Nurse Navigators in conducting outreach for patients recently discharged to schedule follow-up visits with their primary care providers.
  • Utilize educational and behavioral change strategies to encourage patient engagement with the care team.
  • Exhibit exceptional written, verbal, and listening communication skills, along with strong relationship-building and problem-solving abilities in patient care coordination.

Professional Development: Maintain compliance with all professional continuing education units (CEUs) as mandated by state and regulatory standards.

This is a full-time position.