The Care Coordinator will work with other medical professionals to provide the best healthcare possible to patients. This coordinated, team-based care will be provided to individuals through effective partnerships with patients, caregivers, families, community resources, and their physician with the Care Coordinator serving as the primary contact point, advocate, and resource. The Care Coordinator will work in collaboration and continuous partnership with the patient to ensure that the patient understands every aspect of their care and will promote adherence to a care plan developed in coordination with the patient, primary care provider, and family / caregivers. The Care Coordinator will connect patient to relevant community resources with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reduction health costs by managing relationships with tertiary care providers, transitions-in-care, and referrals. This individual will also work with administration to create policies and make decisions that are in the best interest of patients and will facilitate a shared goal model across settings of care to achieve coordinated high-quality care that is patient and family centered.
Responsibilities Promote timely access to appropriate careIncrease utilization of preventative care, reduce emergency room utilization and hospital readmissionsProvide medication reconciliationAssess patient’s unmet health and social needsDevelop a care plan with the patient, family/caregiver, and providers and monitor adherence to these care plans evaluating effectiveness, patient progress, and facilitating change as neededFacilitate patient access to appropriate medical and specialty providersEducate patient and family/caregivers about relevant community resourcesCultivate 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 referralsAssist in the identification of high-risk patientsImplement an effective internal tracking system for identified patientsPromote health behaviors in all populations and ensure navigation assistance with community resourcesEnsure active tracking of test results, medication management, and adherence to follow-up appointments QualificationsEducation
Must be a current licensed Practical or Registered Nurse
or have obtained a bachelor’s or master’s degree in Social Work
Minimum Work Experience
2 + years of experience in a clinic, hospital, or quality management environment
Required Skills, Knowledge, and Abilities
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriersExperience in, and sensitivity to, the unique dynamics of an integrated hospital systemExposure to and participation with health IT systems and data reportsDemonstrated skills in planning, organizing, decision making, analytical thinking, and communication requiredDemonstrated skills in Quality Improvement and operational improvements (e.g. “Lean”) methods.