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Care Coordinator
2 months ago
**Job Title:** Care Coordinator - LATS Program
**Job Summary:**
The Care Coordinator - LATS Program works as part of a team to provide admission screening and intake, care planning, case management, patient education and health navigation, and clinical care within the scope of practice, for patients being discharged from the hospital setting without stable housing for recovery.
Key Responsibilities:
- Huddle daily with RCP team to create and implement action plans to perform transition of care visits for patients being discharged from hospitals, follow up with outside provider recommendations after outpatient visits and ensure that treatment recommendations and medication changes are acknowledged and actualized.
- Assist with coordination of patient referral from inpatient hospital stays, coordinate hospital follow-up visits, and work with RN to act as a liaison between patients and outside agencies.
- Register and update patient information in EHR, including REALD and Annual Verification Forms while assisting RN with intake to RCP.
- Document medical information in patient's electronic health records.
- Collect proper documentation of patient financial and insurance status, including patient access to OHP enrollment through shelter partner or VG, as appropriate.
- Coordinate care and facilitate connections to appropriate providers (e.g., PCP, home health, pharmacies, specialty care) ensuring health information is transferred to providers.
- Provide support for referrals (schedule appointments as necessary, track, provide records and obtain reports).
- Facilitate patient access to obtain durable medical equipment (DME), wound care, oxygen, and incontinence supplies (as needed).
- Use the Collective Medical Platform to ensure real-time coordination of care between VG and hospital settings.
- Coordinate with shelter case management to address SDOH and other non-clinical needs.
- Share pertinent health information with additional providers (as indicated), and with the patient and their community-based provider at program discharge, including medication list, PCP and specialty provider contacts, and case management and community resources.
- Educate patients on how to utilize after-hours number or daytime nurse triage to address immediate clinical needs.
- Support language access using an interpretation service as needed.
- Assist with scheduling outside transportation services.
- Provide culturally and clinically appropriate patient education and information to patients in accordance with training and experience.
- Travel to clinics, hospitals, agencies, etc. as needed.
- Handle protected health information in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Requirements:
- Verbal proficiency in English and Spanish preferred.
- Demonstrated ability to work effectively in a team environment.
- Demonstrated problem solving skills in a complex environment.
- Ability to take initiative to proactively organize and manage the responsibilities of the job.
- High degree of integrity and professionalism.
- Demonstrated effective interpersonal relationship and customer service skills.
- Good organizational and time management skills.
- Good working knowledge of local social service resources or ability to acquire and use this knowledge and information expeditiously.
- Desire to work with the Hispanic community and carry out the mission of the Center.
- Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
- Basic level of proficiency with Microsoft Office (Word, Excel, Outlook) and ability to use other computer programs and applications (Epic, Collective, LabLink etc.) in ways that facilitate care coordination.
Education and Experience:
- One of the following is required:
- Associate degree in healthcare administration, Social Science, Social Work, or related, or
- Medical Assistant Certification, or
- Four years of experience in a healthcare or social service-related administrative role.
Behavioral Competencies:
- Accountability
- Role model VG's mission, vision, and shared values
- Customer-Focus
- Listen to the voice of the customer and strive to delight them by exceeding their expectations.
- Teamwork
- If someone needs help, help them.
- Initiative
- Be innovative, apply fresh ideas, and continuously improve how you do your work.
- Confidentiality
- Maintain strict confidentiality and respect the privacy of others.
- Ethical
- Demonstrate integrity, honesty, and stewardship in all encounters at work.
- Respect
- Demonstrate consideration and appreciation for co-workers and patients.
- Communication
- Demonstrate the ability to convey thoughts and ideas as well as understand perspective of others.