JOB SUMMARY:

The primary responsibility of the Community Care Coordinator working under the oversight of assigned Community Care Manager or Supervisor is to promote the health and welfare of assigned patients through face to face and/or phone outreach and e-mail communications. The Community Care Coordinator is a member of Interdisciplinary Team (IDT) caring for the patient in ensuring the patient’s individual needs are identified and addressed in a timely manner, act as patient advocate to address primary physical and social needs including assessing and linking community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family.

• Accountable for contacting patients, caregivers and families to ensure preventive services are received by assigned patients
• Decrease identified care gaps by working with primary care offices to obtain timely appointments for assigned patients including Post-hospital discharge and Annual Wellness Visits where appropriate
• Understand and apply principles of population health management to identify patients with uncontrolled chronic conditions and/or rising risk indicators and refer to Community Care Manager accordingly
• Provide care coordination services for patients requiring chronic care management
• Ensure that appropriate patients receive annual physical exam and/or annual health risk assessment (HRA) including completion of required documentation by payer contract
• Evaluates and refers patients to Community Care Manager, as appropriate, when acuity changes
• Follow treatment plans of patient as written by provider and/or Community Care Manager
• Where appropriate, assesses patient in the home environment and assist the IDT to evaluate the patient’s needs in their home to facilitate the patient’s ability to improve self-management skills.
• Leads the IDT discussion in home management of assigned patients including facilitation of home care referrals where appropriate
• Where appropriate, facilitate discussion with patient and family members on advance directives.
• Provides expertise in linking patients with community resources such as prescription assistance
• Assist patients in navigating social and health services such as enrollment in social security, Medicaid, Medicare, and other appropriate insurance plans
• Assesses and assist patient’s safety needs in home, i.e. fall risk and order equipment where necessary to promote patient independence
• Assist with self-management of medication, i.e. setting up medication boxes if needed.
• Refer patient or family to community resources for housing or treatment to assist in recovery from chronic illness and following through to ensure service efficacy.
• Educate and aid family members to assist them in understanding, dealing with, and supporting the patient with a chronic illness and end of life practices
• Interview clients about activities of daily living to determine needs and link with community resources where appropriate
• Reviews and updates Provider and Community Care Manager of patients’ living conditions and ability to adhere to plan of care and coordinate treatment goals
• Assess, monitor, and evaluate, the patient’s progress in the home with respect to treatment goals.
• Documents findings in health care record following System approved protocols.
• Perform the tasks necessary for collecting data, maintaining records, developing, and utilizing assessment and measuring tools relative to patient care and wellness practices.
• Obtain and coordinate access with primary care providers and other specialty providers including behavioral health ensuring necessary records and documentation of referrals are completed and reconciled.
• Educate patients on availability of resources for primary care and acute care along with alternative community programs and services that promote sound health, lifestyle, and well-being.
• Schedule timely and appropriate office and follow-up visits at/with and or other health care providers such as dentists, public health, social services, or any other outreach workers needed to provide comprehensive and quality care for patients
• Be able to work independently with minimal supervision
• Community outreach activities as assigned

REQUIREMENTS:

• Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years acute care and/or ambulatory practice experience
• Preferably with experience working with care managers from acute care setting or health insurance and/or other payer entities.
• Good verbal and communication skills and organizational skills a must
• Competency in electronic medical records desirable
• Bi-lingual preferable (market specific)