Patient Care Coordinator

2 weeks ago


Yuma, Arizona, United States sunsethealth Full time

Role Overview: The Nurse Care Manager acts as a vital link for patients, caregivers, and families, guiding them through the healthcare system while advocating for their needs during interdisciplinary discussions.

Collaboration: Works closely with a patient-centered medical home team, which includes healthcare providers, pharmacists, behavioral health specialists, and community health workers, to ensure optimal patient outcomes.

Patient Interaction: Engages with patients and their support systems to facilitate seamless care transitions, service coordination, and effective care planning.

Health Assessment: Identifies potential health risks, performs ongoing evaluations, and maintains comprehensive electronic health records for each patient referred.

Care Coordination: Collaborates with health plans and hospitals to monitor patients recently discharged from hospital settings or emergency departments, ensuring timely follow-up and support.

Barrier Identification: Proactively recognizes and addresses obstacles to care, maintaining an updated directory of community resources for patients and their families.

Support Services: Provides necessary support and referrals as recommended by the interdisciplinary teams to enhance patient and family well-being.

Quality Assurance: Upholds care quality by adhering to evidence-based practices, evaluating health outcomes against established goals, and making informed recommendations to the care team.

Quality and Compliance Participation: Engages in quality improvement initiatives through incident reporting and identifying enhancement opportunities. Contributes to compliance efforts by preventing, detecting, and reporting fraud, waste, and abuse while ensuring patient confidentiality as per HIPAA regulations. Participates in infection control protocols to maintain safety standards.

Additional Responsibilities: Other duties as assigned.



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