Position Title: Care Management Coordinator 

Reports To: Director, Care Management 

Department: Care Management 

FLSA Status: Non-Exempt 

Job Summary:

Accomplishes patient's care by assessing treatment needs; developing, monitoring, and evaluating treatment plans and progress; facilitating interdisciplinary approaches; monitoring staff performance. Assist patients with our disease management programs and completing of preventive health screenings. 

Essential Duties & Responsibilities:

• Determines patient’s requirements by completing HRA (Health Risk Assessments); determining need for therapeutic medical, psycho-social, and psychiatric evaluations; reviewing general evaluations, treatment objectives, and plans. 
• Establishes treatment programs by setting schedules and routines; coordinating services being provided; arranging resources, including transportation. 
• Monitors cases by verifying patients' attendance; observing and evaluating treatments and responses; advocating for needed services and entitlements; obtaining additional resources; intervening in crises; providing personal support. 
• Maintains patient’s records by reviewing case notes; logging events and progress. 
• Communicates patient’s progress by conducting interdisciplinary care team meetings and evaluations; disseminating results and obstacles to therapeutic team and family; identifying treatment influences. 
• Coordinate discharge and post-discharge requirements; orienting and training family members; providing resources.
• Creating and updating care plans for all patients actively enrolled in Care Management/Disease management program 
• Implementing cost-saving actions and improving Generic Dispensing rates (Target 91% GDR) - Reduce hospital admissions by coordinating outpatient care 
• Reduce hospital re-admissions (Target 10% readmission rate) 
• Admits new patients by reviewing records and current member summary; conducting orientations. 

Additional Duties & Responsibilities:

• Improves staff competence by providing educational resources; balancing work requirements with learning opportunities; evaluating the application of learning to changes in treatment results. 
• Improving HEDIS/Preventive health screenings including coordinating appointments with specialist/vendors (Target 5 Stars in all part C and Part D measures, 4 stars in readmissions. 
• Provide all patients with educational information to improve knowledge of disease process and all required preventive health screenings. 

Supervisory Responsibilities:

No supervisory responsibilities 

Education & Experience:

RN, LPN, Foreign medical practitioner or equivalent medical experience.

Knowledge, Skills & Proficiencies:

• Skill in operating phones, personal computer, software and other IT systems. 
• Skill in oral communication
• Ability to communicate with employees, patients and other individuals in a professional and courteous manner. 
• Ability to pay close attention to detail and to ensure accuracy of reports and data. 
• Bilingual (Fluent in English and Spanish)

Physical Requirements/Working Environment:

This position works under usual office conditions. The employee is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include ability to lift up to 50 lbs. 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Travel:

Work will involve some driving/traveling to assigned clinics.

Disclaimer:

The above information on this description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties and responsibilities to this job at any time.