Care Coordinator
3 days ago
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. This position is part of the Interdisciplinary Team (IDT) that cares for patients, ensuring their individual needs are identified and addressed in a timely manner. The Community Care Coordinator acts as a patient advocate, addressing primary physical and social needs, and linking patients with community resources.
Key Responsibilities- Contact patients, caregivers, and families to ensure preventive services are received.
- Decrease identified care gaps by working with primary care offices to obtain timely appointments.
- Apply principles of population health management to identify patients with uncontrolled chronic conditions and refer to the Community Care Manager.
- Provide care coordination services for patients requiring chronic care management.
- Ensure patients receive annual physical exams and health risk assessments, including completion of required documentation.
- Evaluate and refer patients to the Community Care Manager when acuity changes.
- Follow treatment plans written by providers and/or the Community Care Manager.
- Assess patient needs in the home environment and facilitate self-management skills.
- Lead IDT discussions on home management and facilitate home care referrals.
- Facilitate discussions with patients and family members on advance directives.
- Link patients with community resources, such as prescription assistance.
- Assist patients in navigating social and health services, including enrollment in insurance plans.
- Assess and assist patient safety needs in the home.
- Assist with self-management of medication.
- Refer patients or family members to community resources for housing or treatment.
- Educate and aid family members in understanding and supporting patients with chronic illnesses.
- Interview clients about activities of daily living to determine needs and link with community resources.
- Review and update provider and Community Care Manager on patients' living conditions and ability to adhere to the plan of care.
- Assess, monitor, and evaluate patient progress in the home.
- Document findings in the healthcare record.
- Collect data, maintain records, and develop assessment and measuring tools relative to patient care and wellness practices.
- Coordinate access with primary care providers and other specialty providers.
- Educate patients on available resources for primary care and acute care.
- Schedule timely and appropriate office and follow-up visits.
- Work independently with minimal supervision.
- Perform community outreach activities as assigned.
- Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years 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).
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