Care Coordinator - Full Time-Days

POSITION SUMMARY

Care Coordinators function as liaisons between patients, providers, and the healthcare system. Care Coordinators ensures that patient needs, discharge planning, and care coordination efforts are all coherent with care management criteria. Care coordinators must remain cognizant of patient necessity, levels of care, medical conditions, discharge plans, and medications. Duties may also include patient instruction, care orientation, and coaching.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Care Coordination:

• Assists patients through the healthcare system by operating as a patient advocate and health systems navigator.
• Coordinates continuity of patient care with external healthcare organizations and facilities.
• Coordinates continuity of patient care with patients and families/caregivers following hospital admission, discharge, and Emergency Department visits.
• Reports care barriers and challenges to physician or designee.
• Conducts comprehensive, preventive screenings for patients and/or assists all support staff in daily patient interactions as needed.
• Participate in the implementation of the Enhanced Care Management (ECM) with the goal of ensuring that eligible Medi-Cal beneficiaries receive enhanced care management and coordination.
• Supports patient self-management of disease processes and promotes behavioral modifications self-intervention.
• Promotes clear communication amongst interdisciplinary care team members by ensuring awareness regarding patient care plans.
• Facilitates patient medication management based upon standing orders and protocols.
• Participates as a successful team associate supporting data collection, health outcomes reporting, clinical audits, and pragmatic evaluation.
• Participates in the evaluation of clinical care, utilization of resources, and development of new clinical tools, forms, and procedures.
• Under the direction of the Manager of Population Health and Health Programs Supervisor determine which projects will take priority at any time for the Martin Luther King Jr. Community Medical Group
• Coordinates project plans including project timelines
• Provide direction and support to the project team as required
• Tract project deliverables using appropriate tools
• Identify project risks and recommend appropriate resolutions
• Projects defined; Metrics, Physician Dashboards, and Quality Metrics
• Assists in creation and submittal of Medical Group invoices
• Other duties as assigned.