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Patient Care Coordinator
2 months ago
Position Overview
The Care Coordinator collaborates with the designated clinical team to pinpoint patients who are most likely to gain from care coordination services. This includes evaluating patients' risk factors and determining the necessity for care coordination, clinical utilization management, and preventive care services.
Role Summary
REACH, which stands for REadmission Advocates Collaborating in Healthcare, is a program that extends care management for patients post-hospital discharge. This initiative aids in connecting patients and their families with community resources, referrals, and additional services that facilitate healthcare management and improve quality of life. REACH services are accessible at all facilities within the organization.
Work Schedule: This is a flexible position providing coverage across various facilities, requiring up to three days a week of service as needed. Standard hours are from 8:00 AM to 4:30 PM.
Key Responsibilities
- Lead efforts to ensure seamless and consistent care across all healthcare settings, including inpatient, emergency, and outpatient services, focusing on comprehensive discharge planning and follow-up care.
- Establish effective working relationships with Patient and Family Counselors, Social Workers, and Utilization Review nurses to engage patients and families in collaboration, advocacy, and problem-solving to enhance their functional abilities and ensure timely discharge planning.
- Monitor daily progress towards discharge plans and adjust as necessary based on changes in patient conditions or family needs, prioritizing those at the highest risk for complications or readmissions.
- Educate patients and families with chronic conditions on evidence-based care standards and self-management strategies.
- Identify support needs for patients and their families, develop actionable plans, and provide guidance in implementing self-management strategies.
- Facilitate understanding of the healthcare system for patients and families, fostering relationships across various care settings.
- Ensure patients have access to necessary prescriptions, durable medical equipment, and other identified services.
- Contribute to team problem-solving through effective communication, collaboration, data collection, and evaluation of treatment outcomes, including tracking patient progress towards care plan goals.
- Advocate for patients to optimize their healthcare needs, addressing safety, physical, legal, and financial well-being.
- Refer patients to educational resources regarding healthcare delivery, reimbursement systems, community agencies, and other relevant services.
- Utilize available IT resources to facilitate reporting and maintenance of specified patient populations, aiming to improve health outcomes through evidence-based guidelines.
- Participate in clinical outcome measurement and strategy identification to promote population health.
- Ensure patient safety in all job functions by adhering to established policies, procedures, and standards.
- Maintain regular attendance in accordance with organizational policies and applicable regulations.
- Comply with all organizational policies and procedures.
- Provide clinical treatment interventions under the supervision of licensed Mental Health Therapists, assisting with patients' psychosocial adjustments throughout their care continuum.
- Facilitate psychosocial support groups.
- Deliver mental health education and support to patients and families.
- Exhibit strong analytical and team-building skills, with the ability to prioritize tasks and work independently.
- Demonstrate knowledge and skills necessary to provide age-appropriate care, understanding growth and development principles.
- Be aware of medical/legal issues, patient rights, and compliance with regulatory standards.
- Perform additional duties as assigned.
Education/Training:
- A Master's degree from an accredited institution in Social Work, Mental Health, Psychology, or Marriage and Family Therapy is required.
- A minimum of two years of direct clinical experience, with a focus on the relevant population. Successful completion of a Master's level internship in the relevant area may substitute for the required experience.
