This position is the center point for outpatient care of patients with chronic medical issues such as Chronic Pain, Stroke, Multiple Sclerosis, Parkinson's, Dementia, Cancers, and others related to neurological conditions. The care coordinator is an active member of the multidisciplinary team who collaborates with the providers and other clinical support staff in the development, execution, and evaluation of the multidisciplinary care plan of these at-risk patients.
To serve as a liaison between patients, physicians, and our hospital partners to assure that patients with chronic neurological conditions are cared for in an optimal manner.
This position will engage in our efforts to improve patient satisfaction, clinical outcomes, and operational efficiency.
Will conduct video and telephonic visits to patients to ensure compliance with treatment protocols and to determine when additional medical intervention may be required to assure optimal outcomes.
This coordinator assists patients and families as they receive care from different specialties, arrange follow up so that transitions from service to service were as smooth as possible, make sure medical information/record are transferred, schedules and make sure consults/procedures with other services are scheduled and occur.

• Facilitates clinical management and continuity of care for patients enrolled in one of our care coordination programs, i.e., Chronic Care Management (CCM), Principal Care Management (PCM), and Transitional Care Management (TCM).
• Responsible for the CCM program crossing many departments, and service lines to follow all CCM care delivered.
• Reviews medical records of CCM patients and analyzes data regarding the provision of care to ensure proper compliance and timeliness of care.
• Populates databases in various systems to assure that data is retrievable, and that analysis can be performed.
• Provides education and guidance to team and all respective clinical staff on signs and symptoms of chronic conditions, the need to follow treatment protocols, assessment tools and other guidance as required.

Requirements

• A minimum of three (3) years of related experience, preferably in an outpatient clinic setting with experience as a patient care giver, educator, or patient advocate.
• LICENSURE OR CERTIFICATION: LPN preferred or 5 years' experience as certified MA.
• Current Basic Life Support (BLS)
• Effective Communication Skills