Senior Care Coordinator

Job Requirements

Position Summary

Responsible for providing telephonic based education and care management for in-patient and out-patients with chronic diseases and their caregivers; assisting clients with resources and support needed to manage their disease process in such a way that decreases their risk for complications, emergency room visits and hospitalizations. Properly document patient interactions as part of the care team. Responsible for assisting with community services, and quality improvement for the department. Take responsibility; keep commitments; complete tasks on time. Volunteer readily; take independent actions; ask for and offer help when needed.

Minimum Requirements

Education

• High School Diploma

Experience

• Prior experience working as a Medical Assistant and/ or working in a medical setting interacting with patients and clinical information

License/Registration/Certifications

• Valid driver's license with good driving record
• Certified Medical Assistant and/or LPN, or Assessment-Based Recognition in Order Entry (ABR-OE) Credential

Preferred Requirements

Preferred Education

• Associate/ Bachelors

Preferred Experience

• N/A

Preferred License/Registration/Certifications

• N/A

Core Job Responsibilities

• Telephonically, provide care coordination, coaching, and motivational interviewing to members identified as moderate risk after an inpatient stay. Complete the documentation necessary in Epic to facilitate communications and billing for Transitional Care Management (TCM) codes.
• Telephonically, provide care coordination, coaching and motivational interviewing to members identified with two or more chronic diseases. Complete the documentation necessary in Epic to facilitate communications and meet the requirements for billing Chronic Care Management (CCM) codes.
• Conduct telephonic outreach to members identified as needing an Annual Wellness Visit. Complete the required interview with the patient or caregiver prior to the office visit.
• Build and maintain positive working relationships with the patients, providers, care managers, agency representatives, supervisors and office staff to ensure successful care coordination and transitions of patients.
• Identify socio-economic issues that affect a patient's overall health and develop health/social management plans and goals for patient and family.
• Identify gaps in care and assists members in utilizing community services, including scheduling appointments, utilizing social services agencies, (including transportation vendors), and assisting with completion of applications for eligible programs.
• Assist with patient medication adherence by instructing the member on current medication list, reviewing medications with member and assist in obtaining refills.
• Educate patients and caregivers on chronic disease self-management (i.e. nutrition, symptom tracking and reporting).
• Responsible for recruitment, engagement, and retention of patients into the program with chronic diseases.
• Must achieve productivity standards, daily, weekly and monthly.
• Must have excellent communication and computer skills.
• Interact with members by phone and/or face to face; may be required to meet member in various health care settings, such as; physician offices, hospital.
• Properly handles member records to ensure compliance with patient health information applicable to the preservation, accuracy, and completeness of communication and/or retention of patient information, meeting all HIPAA regulations and the HITECH Act provisions as required by law.
• Serves as a back up to other Senior Care Coordinators.
• Must be willing to work outside normal business hours on occasion.
• All other duties as assigned.