Patient Care Coordinator

2 weeks ago


Springfield, Vermont, United States Springfield Medical Care Systems, Inc. Full time

Springfield Medical Care Systems, Inc. is a prominent independent health organization focused on delivering comprehensive care through a network of Patient-Centered Medical Homes. We are currently seeking a Clinical Care Coordinator to join our dedicated team.

In this essential position, you will work closely with individuals aiming to prevent and manage chronic health issues. Your responsibilities will include identifying patient priorities, formulating care plans, and coordinating their execution in collaboration with patients, their healthcare teams, and community resources.


Key Responsibilities:


• Uphold and advance our mission to engage with and support our community in achieving optimal health and wellness.

• Evaluate patients' clinical, social, and functional needs to determine their priorities and desired treatment outcomes.

• Collaborate with patients and their care teams to create a comprehensive care plan that includes immediate, short-term, and long-term objectives tailored to the patient's needs.

• Exhibit a thorough understanding of the patient's diagnosis, prognosis, and care requirements, while also addressing potential costs and barriers to achieving health goals.

• Facilitate smooth transitions of care by reaching out to patients and coordinating with relevant service providers post-discharge to minimize readmission rates.

• Communicate effectively with patients and their families, ensuring a patient-centered approach while working alongside other team members to deliver outstanding service.

• Foster positive relationships and demonstrate exceptional customer service skills, collaborating effectively with all healthcare providers, team members, patients, and their families.

• Assist patients in accessing appropriate medical and specialty services, as well as additional support from the care coordination team.

• Provide Chronic Care Management services to eligible patients as necessary.

• Ensure meticulous tracking of test results, medication management, and adherence to follow-up appointments.

• Support patients in self-managing their conditions and implementing behavior modification strategies.

• Conduct proactive outreach to selected patients, including home visits when required for assessment and engagement.

• Participate in quality improvement initiatives by collecting and analyzing relevant data.


Qualifications:
• Experience in Care Planning.

• Minimum of two (2) years of nursing experience.

• Strong communication skills.

• Proficiency in Microsoft Office and general computer skills.

• Current LPN License.

• Preferred: One (1) to two (2) years of experience in case management.

• Preferred: Current RN License.

All candidates are encouraged to submit a cover letter that outlines their qualifications for this role, along with completing the application process.

Proof of COVID vaccination or an exemption request is required prior to employment.



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