The Care Coordinator serves as a link between the patient and the healthcare organization. Guides patients through their care plans and ensures that they are following the best methods to a healthy lifestyle.
Care Coordinators handle a larger volume of coordination activities with patients and work in an integrated manner with care manager for more complex activities. Their activities include outreach to patients for onboarding and risk stratification through the application of the Health Risk Assessment (HRA). They may coordinate preventative health services and will be involved in the information exchange where appropriate and routine communication with the patient and families. They may also participate in patient teaching activities for general health or at a disease-specific level as their training permits. Care Coordinators also work with Low Intensity patients with identified social factors by providing them with referrals to community agencies, educational resources, and appointments as directed by the Care Manager or Provider
Essential duties and responsibilities may include:
Acts as peer support for enrolled patients which includes advocacy as patients navigate the medical system and relationship building with individuals and their families
Administers the Health Risk Assessment
Reports any health care challenges identified to the Care Manager
Maintain and distribute approved disease specific education to identified patient panel and community
Provides reminder phone calls for various scheduled appointments or follow-up after scheduled appointments
Assists patient with obtaining specialty care visits, Primary Care Provider visits, and ancillary services such as labs/diagnostics, including making appointments as needed
Makes at home visits to ensure the patients are following their care plans.
Enter and maintain electronic records, compile reports and complete other program documentation in a timely manner (e.g. progress notes, incident reports, client track, letters, etc.); other administrative responsibilities as needed
Obtains copy of medical records such as CCCD discharge summary or discharge information from Primary Care Provider, hospital case manager or discharge planners and others involved in patient's care.
Handles protective health information in a manner consistent with the Health Insurance Portability and Accountability Act (HIPPA)
Assist and guide patients in redetermination, reinstatement of health insurance plan & follows guidelines provided to medical home for this process.
Other duties and responsibilities as directed
Bachelors Degree, Associates Degree or 3 years or more of health related experience
Must be Bilingual (English/Spanish)
Previous experience in a community outreach setting/ health care setting highly preferred
Proficient in Electronic Health Record, Microsoft Word and Excel
Exceptional organizational and interpersonal skills, with attention to detail required; strong oral/written communication skills is a must
Ability to work collaboratively in a team and manage multiple priorities, utilize effective time management skills, and exercise sound administrative and clinical judgment
Demonstrated ability to work well with people of various ages, backgrounds, ethnicities, and life experiences
Additional Salary Information: Based on experience