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Title

Care Coordinator 

Description

Job Overview:

The Care Coordinator is a clinically trained patient advocate striving to coordinate the delivery of comprehensive, quality care and services at the right time. The Care Coordinator is an integral part of the primary care multidisciplinary team. The care coordination program strives to achieve the best quality outcomes, highest patient satisfaction, highest provider/staff satisfaction and the most cost effective care.

Responsibilities:

  1. Identifies and recommends appropriate patient referrals to eligible programs within Boice-Willis Clinic (BWC) and other entities such as; Health Education services, Physical Therapy, Personal Health Team, Health Advisors, Complex Case Management, etc.

  2. Coordinates the care of the high-risk targeted population in an appropriate, efficient and cost-effective manner.

  3. Conducts needs assessment to plan projects, coordinates and monitors support services/staff, develops timelines, education needs of physicians and staff.

  4. Assists in developing process and procedures that ensures thorough review of multiple patient level actionable reports; to include but not limited to Gaps in Care, Quality reports, and ER/Discharge patient lists in order to identify at-risk patients.

  5. Evaluates the effectiveness, necessity, and efficiency of the treatment plan and communicates with the PCP and health care delivery team to recommend changes.

  6. Educates self on the critical elements associated with the target population such as disease states, diagnoses (ICD-10) codes, utilization patterns, clinical treatment guidelines, financial processes, regulations, data resource quality and availability.

  7. Assists with Transitional Care Management.

  8. Communicates clearly with all team partners.

  9. Act as the community resource expert for BWC's high risk members, including transition of life/hospice resources, direct acute admits and home health/infusion needs.

  10. Identifies cases appropriate for long term case management and follows process for referral.

  11. Works effectively with available Care Coordinators to coordinate case transition when needed.

  12. Identify and build effective relationships with a network of community, government and knowledge resources.

  13. Establish and maintain a professional, collaborative positive relationship with the patient, family, physician(s), and other providers to assess the options for care and use of benefits and community resources.

  14. Maintains appropriate documentation and tracking as required by BWC and insurance companies.

  15. Coordinates and identifies high risk population with a history of poly-pharmacy, to improve quality outcomes with appropriate support services in managing pharmacy needs.

  16. Act as liaison between BWC and other healthcare entities.

  17. Educate team partners in regards to BWC's health management programs.

  18. Represents BWC as a member of a cross-functional project team.

  19. All other assignments as directed by supervisor.

 
Position Requirements

Minimum Qualifications:

  1. Current licensed LPN or CMA.

  2. Excellent oral and written communication skills,

  3. Computer skills in eCW, Word, and Excel

  4. Must be able to work in a team environment and exhibit flexibility and enthusiasm in learning new information and developing new skills quickly.

  5. Demonstrate commitment to ongoing education preferred.

  6. Experience working with high-risk patients preferred.

  7. Experience in project development and working in a team environment preferred.

 
About the Organization  

This position is currently accepting applications.

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