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Care Coordinator

2 months ago

Baltimore, Maryland, United States LifeBridge Health Full time
Job Summary

The Community Care Coordinator plays a vital role in promoting the health and well-being of patients by providing face-to-face and phone outreach, as well as email communications. As a member of the Interdisciplinary Team (IDT), this role ensures that patients' individual needs are identified and addressed in a timely manner.

Key Responsibilities
  • Contact patients, caregivers, and families to ensure preventive services are received by assigned patients.
  • Decrease identified care gaps by working with primary care offices to obtain timely appointments for assigned patients, including post-hospital discharge and annual wellness visits where appropriate.
  • Understand and apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and refer to the Community Care Manager accordingly.
  • Provide care coordination services for patients requiring chronic care management.
  • Ensure that appropriate patients receive annual physical exams and/or annual health risk assessments (HRAs), including completion of required documentation by payer contract.
  • Evaluate and refer patients to the Community Care Manager as appropriate when acuity changes.
  • Follow treatment plans of patients as written by providers and/or Community Care Managers.
  • Assess patients in the home environment and assist the IDT to evaluate the patient's needs in their home to facilitate the patient's ability to improve self-management skills.
  • Lead the IDT discussion in home management of assigned patients, including facilitation of home care referrals where appropriate.
  • Facilitate discussion with patients and family members on advance directives.
  • Provide expertise in linking patients with community resources, such as prescription assistance.
  • Assist patients in navigating social and health services, including enrollment in social security, Medicaid, Medicare, and other appropriate insurance plans.
  • Assess and assist patients' safety needs in the home, including fall risk and ordering equipment where necessary to promote patient independence.
  • Assist with self-management of medication, including setting up medication boxes if needed.
  • Refer patients or family members to community resources for housing or treatment to assist in recovery from chronic illness and follow through to ensure service efficacy.
  • Educate and aid family members to assist them in understanding, dealing with, and supporting patients with chronic illnesses and end-of-life practices.
  • Interview clients about activities of daily living to determine needs and link with community resources where appropriate.
  • Review and update provider and Community Care Manager on patients' living conditions and ability to adhere to the plan of care and coordinate treatment goals.
  • Assess, monitor, and evaluate patients' progress in the home with respect to treatment goals.
  • Document findings in the healthcare record following System-approved protocols.
  • Perform tasks necessary for collecting data, maintaining records, developing, and utilizing assessment and measuring tools relative to patient care and wellness practices.
  • Obtain and coordinate access with primary care providers and other specialty providers, including behavioral health, ensuring necessary records and documentation of referrals are completed and reconciled.
  • Educate patients on the availability of resources for primary care and acute care, as well as alternative community programs and services that promote sound health, lifestyle, and well-being.
  • Schedule timely and appropriate office and follow-up visits at/with and/or other healthcare providers, such as dentists, public health, social services, or any other outreach workers needed to provide comprehensive and quality care for patients.
  • Be able to work independently with minimal supervision.
  • Perform community outreach activities as assigned.
Requirements
  • Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years of acute care and/or ambulatory practice experience.
  • Preferably with experience working with care managers from acute care settings or health insurance and/or other payer entities.
  • Good verbal and communication skills and organizational skills are a must.
  • Competency in electronic medical records is desirable.
  • Bilingual is preferable (market-specific).