CORE JOB SUMMARY
Care Coordinator will be working with patients visiting them in their home on care management and coordination of patients that are in one of our post-acute or chronic care programs. The average patient may have between three and six interactions per month; others, depending on their self-management interests and/or current health risk status, will require considerably more interactions. The Care Coordinator works in collaboration and continuous partnership with other team members, ultimately reporting to RN Manager. The patients are chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers, staff, and community resources all work in a team approach.
Specific responsibilities of the position include and are not limited to:
CORE JOB FUNCTIONS AND RESPONSIBILITIES
· Accountability throughout the care to superiors in management
· Promote timely access to appropriate care.
· Increase utilization of preventative care.
· Reduce emergency room utilization and hospital readmissions.
· Increase comprehension through culturally and linguistically appropriate education.
· Create and promote adherence to a care plan and medication reconciliation developed in coordination with the patient, primary care provider, and family/caregiver(s).
· Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals.
· Increase patients’ ability for self-management and shared decision-making.
· Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
· Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
· Work with patients to plan and monitor care: Assess patient’s unmet health and social needs.
· Gather independent medical history to help develop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).
· Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.
· Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time.
· Facilitate patient access to appropriate medical and specialty providers.
· Educate patient and family/caregiver(s) about relevant community resources.
· Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed.
· Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
· Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), add these to the patient registry (or flag in EHR).
· Attend all Care Coordinator training courses/webinars and meetings.
· Provide feedback for the improvement of the Care Coordination Program.
· Follow the Mission, Vision and Culture of the company
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.
CORE QUALIFICATIONS AND SKILLS
· Licensed and credentialed as a Certified Medical Assistant (CMA) or Medical Assistant (MA)
· Proficiency in communication technologies (email, cell phone, etc.).
· Highly organized with ability to keep accurate notes and records.
· Experience with health IT systems, EMRs and reports is preferred.
· Must have reliable transportation to travel to patient's home.
· English and Creole. Spanish is a plus.
Job Type: Full-time
Pay: $17.00 - $20.00 per hour
Expected hours: No less than 40 per week
Work Location: On the road
