The purpose of this position is to have a Care Coordinator that is responsible to assist the patient, their families and provider across all aspects of their health care continuum. The care Coordinator is the liaison between the patient and the provider with an optimum goal of meeting the patient's individualized needs, ultimately improving quality of life which will result in positive patient outcomes through communication, education and coordination. Essential Duties: Promotes and reinforces the Patient Centered Care Model. Promotes timely access to all aspects of care. Reduce emergency room utilization, hospital admissions as well as readmissions. Promote adherence to care plans developed in coordination with the patient, Primary Care provider and family. Provides excellent customer service. Implements care coordination and planning techniques. Assist patients in navigating through the healthcare continuum. Schedules appointments to ensure the patient is getting follow up with primary care provider and all specialists. If patient requires referral to other services, the Care Coordinator will assure that authorization and referrals are completed. Coordinate appointments with other services/practices and advises patient accordingly. Obtain lab results, diagnostic studies for ancillary services; consult notes and other medical information in preparation for patient’s upcoming appointment. Uses risk stratification tools to identify gaps in treatment Document in EHR all encounters with patient and family. Promotes education and provides guidance to patient as directed by the Primary care provider. Empower and educate patients to promote self-management and shared decision-making. Assist patient in accessing transportation to health center, insurance matters, durable medical equipment, prescriptions, etc. Works collaboratively with providers and other care team members to ensure the delivery of quality of care to patients to help bring about best outcomes. Complete Medication Reconciliation. Communicates with a wide variety of people from a diverse socio-economic and ethnic background. Establishes and maintains effective working relationships with all team members. Engage with patients and caregivers to create an environment of collaborative care team. Other duties as assigned within the scope of responsibilities and requirements of position. Follow up with patient as needed to ensure they understand their agreed upon goals; ie making all scheduled appointments, education classes Performs other duties as assigned.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED