Community Care Coordinator
1 month ago
- Baltimore, MD
- GRACE MEDICAL CENTER
- FAM H&W CENTER
- Full-time - Day shift - 8:30am-5:00pm
- Allied Health
- 83356
- $17.00-$26.00 Experience based
- Posted: October 23, 2024
Summary
JOB SUMMARY:
The primary responsibility of the Community Care Coordinator working under the oversight of assigned Community Care Manager or Supervisor is to promote the health and welfare of assigned patients through face to face and/or phone outreach and e-mail communications. The Community Care Coordinator is a member of Interdisciplinary Team (IDT) caring for the patient in ensuring the patient’s individual needs are identified and addressed in a timely manner, act as patient advocate to address primary physical and social needs including assessing and linking community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family.
- Accountable for contacting 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
- Understand and 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
- Ensure that appropriate patients receive annual physical exam and/or annual health risk assessment (HRA) including completion of required documentation by payer contract
- Evaluates and refers patients to Community Care Manager, as appropriate, when acuity changes
- Follow treatment plans of patient as written by provider and/or Community Care Manager
- Where appropriate, assesses patient in the home environment and assist the IDT to evaluate the patient’s needs in their home to facilitate the patient’s ability to improve self-management skills.
- Leads the IDT discussion in home management of assigned patients including facilitation of home care referrals where appropriate
- Where appropriate, facilitate discussion with patient and family members on advance directives.
- Provides expertise in linking patients with community resources such as prescription assistance
- Assist patients in navigating social and health services such as enrollment in social security, Medicaid, Medicare, and other appropriate insurance plans
- Assesses and assist patient’s safety needs in home, i.e. fall risk and order equipment where necessary to promote patient independence
- Assist with self-management of medication, i.e. setting up medication boxes if needed.
- Refer patient or family to community resources for housing or treatment to assist in recovery from chronic illness and following through to ensure service efficacy.
- Educate and aid family members to assist them in understanding, dealing with, and supporting the patient with a chronic illness and end of life practices
- Interview clients about activities of daily living to determine needs and link with community resources where appropriate
- Reviews and updates Provider and Community Care Manager of patients’ living conditions and ability to adhere to plan of care and coordinate treatment goals
- Assess, monitor, and evaluate, the patient’s progress in the home with respect to treatment goals.
- Documents findings in health care record following System approved protocols.
- Perform the tasks necessary for collecting data, maintaining records, developing, and utilizing assessment and measuring tools relative to patient care and wellness practices.
- Obtain and coordinate access with primary care providers and other specialty providers including behavioral health ensuring necessary records and documentation of referrals are completed and reconciled.
- Educate patients on availability of resources for primary care and acute care along with alternative community programs and services that promote sound health, lifestyle, and well-being.
- Schedule timely and appropriate office and follow-up visits at/with and or other health care providers such as dentists, public health, social services, or any other outreach workers needed to provide comprehensive and quality care for patients
- Be able to work independently with minimal supervision
- Community outreach activities as assigned
REQUIREMENTS:
- 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 setting or health insurance and/or other payer entities.
- Good verbal and communication skills and organizational skills a must
- Competency in electronic medical records desirable
- Bi-lingual preferable (market specific)
Additional Information
As one of the largest health care providers in Maryland, with 13,000 team members, We strive to CARE BRAVELY for over 1 million patients annually. LifeBridge Health includes Sinai Hospital of Baltimore, Northwest Hospital, Carroll Hospital, Levindale Hebrew Geriatric Center and Hospital and Grace Medical Center, as well as our Community Physician Enterprise, Center for Hope, Practice Dynamics, and business partners: LifeBridge Health & Fitness, ExpressCare and HomeCare of Maryland. Share: Apply Now-
Medical Respite Care Coordinator/Navigator
1 week ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeMedical Respite Care Coordinator/Navigator - Access Carroll Baltimore, MD SINAI HOSPITAL RESPITE SERVICES Full-time - Day shift - 8:00am-4:30pm Staff Nurse 87097 $25.44-$39.43...
-
Medical Respite Care Coordinator/Navigator
1 week ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeMedical Respite Care Coordinator/Navigator - Access Carroll Baltimore, MD SINAI HOSPITAL RESPITE SERVICES Full-time - Day shift - 8:00am-4:30pm Staff Nurse 87097 $25.44-$39.43...
-
Community Support Specialist/Peer Advocate
3 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeCommunity Support Specialist/Peer Advocate - Grace Medical Center - A.C.T. Baltimore, MD GRACE MEDICAL CENTER A.C.T. FFS Full-time - Day shift - 8:30am-5:00pm Clerical/Administrative 86718 ...
-
Patient Care Sitter
3 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Part timePatient Care Sitter Baltimore, MD SINAI HOSPITAL SITTERS-COMPANIONS Full-time w/Weekend Commitment - Night shift - 7:00pm-7:30am Nursing Support 86295 $16.00-$21.00 Experience...
-
Patient Care Sitter
3 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timePatient Care Sitter Baltimore, MD SINAI HOSPITAL SITTERS-COMPANIONS Full-time w/Weekend Commitment - Day shift - 7:00am-7:30pm Nursing Support 86292 $16.00-$21.00 Experience...
-
Critical Care Tech
3 days ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeCritical Care Tech - Sinai Hospital - OROC Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Full-time w/Weekend Commitment - Night shift - 7:00pm-7:30am Nursing Support 86978 ...
-
Critical Care Tech
2 days ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeCritical Care Tech - Sinai Hospital - OROC Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Full-time w/Weekend Commitment - Night shift - 7:00pm-7:30am Nursing Support 86978 ...
-
ED Critical Care Tech
1 month ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeED Critical Care Tech - Grace Medical Center Baltimore, MD SINAI HOSPITAL EMERGENCY ROOM Full-time w/Weekend Commitment - Hours vary - Hours Vary Nursing Support 83134 ...
-
Cat Scan Technologist
1 month ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeCT TECH Baltimore, MD Grace Medical Center FMF-CT SCAN PRN - As Needed - Hours Vary Allied Health 85137 $53.50-$53.50 Posted: October 23, 2024 Apply...
-
Registered Nurse
1 month ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Part timeRegistered Nurse - Outpatient Rapid Observation Center - Sinai Hospital Sign On Bonus Potential: $12,000.00 Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Part-time w/Weekend Commitment - Day shift - 7:00am-7:30pm ...
-
Registered Nurse
4 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Part timeRegistered Nurse - Outpatient Rapid Observation Center - Sinai Hospital Sign On Bonus Potential: up to $9,000.00 Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Part-time w/Weekend Commitment - Day shift - 7:00am-7:30pm ...
-
Registered Nurse
4 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Part timeRegistered Nurse - Outpatient Rapid Observation Center - Sinai Hospital Sign On Bonus Potential: up to $9,000.00 Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Part-time w/Weekend Commitment - Day shift - 7:00am-7:30pm ...
-
Registered Nurse
1 month ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeRegistered Nurse - Outpatient Rapid Observation Center - Sinai Hospital Sign On Bonus Potential: $20,000.00 Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Full-time w/Weekend Commitment - Day shift - 7:00am-7:30pm ...
-
Registered Nurse
4 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeRegistered Nurse - Outpatient Rapid Observation Center - Sinai Hospital Sign On Bonus Potential: Up to $15,000.00 Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Full-time w/Weekend Commitment - Day shift - 7:00am-7:30pm ...
-
Registered Nurse
4 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeRegistered Nurse - Outpatient Rapid Observation Center - Sinai Hospital Sign On Bonus Potential: Up to $15,000.00 Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Full-time w/Weekend Commitment - Day shift - 7:00am-7:30pm ...
-
Registered Nurse
4 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Part timeRegistered Nurse - Outpatient Rapid Observation Center - Sinai Hospital Sign On Bonus Potential: up to $9,000.00 Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Part-time w/Weekend Commitment - Day shift - 7:00am-7:30pm ...
-
Registered Nurse
4 weeks ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeRegistered Nurse - Outpatient Rapid Observation Center - Sinai Hospital Sign On Bonus Potential: Up to $15,000.00 Baltimore, MD SINAI HOSPITAL OUTPATIENT RAPID OBS Full-time w/Weekend Commitment - Day shift - 7:00am-7:30pm ...
-
REGISTERED NURSE
1 month ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeREGISTERED NURSE - SINAI HOSPITAL - Women's Oncology/Med Surg Sign On Bonus Potential: UP TO $20,000 Baltimore, MD SINAI HOSPITAL NURSING WMS/ONC/OTHE Full-time - Day shift - 7:00am-7:30pm Staff Nurse ...
-
Medical Assistant
1 month ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeMedical Assistant - Grace Medical Center Sign On Bonus Potential: $1,000.00 Baltimore, MD GRACE MEDICAL CENTER FAM H&W CENTER Full-time - Day shift - 8:30am-5:00pm Allied Health ...
-
Medical Respite Program Manager
1 week ago
Baltimore, Maryland, 21202, Baltimore, MD, United States LifeBridge Health Full timeMedical Respite Program Manager - Access Carroll Baltimore, MD SINAI HOSPITAL RESPITE SERVICES Full-time - Day shift - 8:00am-4:30pm RN Leader 87095 $44.56-$69.07 Experience...