What are the responsibilities and job description for the Patient Care Coordinator position at Dr. Ramon Reyes MD,PA?
Full Job Description
· Works within a patient-centered care team of providers and clinic staff to identify and care for high-risk patients through transitions of care and their evolving care needs. This supports our mission of value-based care that strives to provide high-quality, low-cost care through prevention and responsible utilization. This is realized through initiatives that aim to reduce ER and urgent-care visits, hospital admissions, and hospital readmissions while improving the health and quality of life of patients.
· Supports longitudinal care of patients with chronic conditions by:
o Assessment of health conditions
o Initiating medication reconciliation for PCP to complete
o Conducting Motivational Interviewing and Self-Management Goal Setting
o Identifying signs that require engagement with the social worker and behavioral health specialist to address social and behavioral health needs.
o Providing patient education
· Supports transition of the patient with chronic conditions from inpatient to outpatient setting by:
o Performing assessment of transitional needs
o Initiating medication reconciliation for PCP to complete
o Establishing and reviewing contingency plan and 24/7 patient support availability
o Providing patient education to empower self-management of chronic conditions.
o Ensure patient follow-up with PCP within 7 calendar days of discharge
o Assisting with post discharge needs including any prescriptions, transportation, durable medical equipment, appointments with PCP, social worker, behavioral health specialist, and/or medical specialists.
o Referring to case management for complex care needs, longitudinal needs, and/or disease management.
· Coordinate with providers to establish or update patient care plan
· Connects patients with resources concerning Behavioral Health and SDOH
· Performs accurate and timely documentation in the electronic medical record
· Participates in daily huddles and Patient Care Coordination (PCC) meetings
· Maintains continued competence in nursing practice and knowledge of current evidence-based practices.
· Safeguards patient information in accordance with HIPAA
· May perform clinical tasks within their scope of practice
· Performs other related duties as assigned
Reports to Lead Physician and Director of Patient Care Coordination
Job Type: Full-time
Pay: Up to $25.00 per hour
Benefits:
- 401(k)
- Health insurance
- Paid time off
Work Location: In person
Salary : $25