Care Coordinator for Patient Wellbeing
6 days ago
LifeBridge Health is seeking a skilled Care Coordinator to promote the health and wellbeing of patients in our community.
About the Role:- As a Care Coordinator, you will be responsible for promoting the health and wellbeing of patients through face-to-face and/or phone outreach and email communications.
- You will work under the oversight of assigned Community Care Manager or Supervisor to ensure timely access to services patients need while respecting their rights and wishes.
Key Responsibilities:
- Contact patients, caregivers, and families to ensure preventive services are received by assigned patients.
- Decrease identified care gaps by working with primary care offices to obtain timely appointments for assigned patients, including post-hospital discharge and annual wellness visits where appropriate.
- Apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and refer to Community Care Manager accordingly.
- Provide care coordination services for patients requiring chronic care management.
- Evaluate and refer patients to Community Care Manager as appropriate when acuity changes.
- Follow treatment plans of patients as written by provider and/or Community Care Manager.
- Assess patient needs in their home environment and assist the Interdisciplinary Team (IDT) to evaluate the patient's needs in their home to facilitate self-management skills.
- Lead IDT discussions in home management of assigned patients, facilitating home care referrals where appropriate.
- Facilitate discussion with patients and family members on advance directives.
- Link patients with community resources such as prescription assistance and social services.
- Assist patients in navigating insurance plans and other benefits.
- Assess and assist patient safety needs in home, including fall risk and ordering equipment where necessary.
- Refer patients or family members to community resources for housing or treatment to assist in recovery from chronic illness and follow through to ensure service efficacy.
- Educate and aid family members to support patients with chronic illnesses and end-of-life practices.
- Interview clients about activities of daily living to determine needs and link with community resources where appropriate.
- Review and update Provider and Community Care Manager on patients' living conditions and ability to adhere to plan of care and coordinate treatment goals.
- Document findings in healthcare records following System-approved protocols.
- Licensed Practice Nurse, Certified Medical Assistant, or trained Patient Care Assistant with 2-3 years acute care and/or ambulatory practice experience.
- Experience working with care managers from acute care settings or health insurance and/or other payer entities preferred.
- Good verbal and communication skills, organizational skills, and electronic medical record competency required.
- Bilingual preferable.
As one of Maryland's largest healthcare providers, we strive to CARE BRAVELY for over 1 million patients annually. Our team of 13,000 employees works together to provide exceptional care and compassion to our community.
Salary: $17-$26 per hour, based on experience.
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