The Care Coordinator is responsible to collaborate with patients identified with vulnerabilities and potentially eligible for case management (e.

g., post-hospitalization, un-controlled diabetics, multi-pharmacy) to assist them in developing and updating an individualized care plan.

In addition, performing outreach to encourage adherence with evidenced-based guidelines to improve the health of the company’s overall population.

This position will support patients and their families in self-management and behavior change.

Location : 551 East 49th Street Hialeah, FL 33013.

Qualifications / Education / Licenses :

• Medical Assistant, Licensed Practical Nurse, or a Foreign Medical Graduate (MD) preferred.
• Minimum 3 years of related experience in a clinic or hospital setting.
• Knowledge of health care and managed care administration policies.
• Phlebotomy certification preferred.
• Must be knowledgeable of MS Office and EHR programs.
• Use relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.
• Understand written sentences and paragraphs in work related documents.
• Actively look for ways to help patients.
• Knowledge of medical terminology.
• Bilingual skills preferred (English / Spanish or English / Creole).

Duties and Responsibilities :

• Ensures that completed screening and tests, specialist notes, and operative reports are filed correctly in the medical chart prior to the patient consultation with the clinician.
• Screens medical charts prior to visit for required HEDIS, 5 Star measures, and medical conditions to alert clinician on date of appointment.
• Receives HEDIS measures as indicated by health plans to ensure all metrics are met for each patient.
• Works with diagnosis data from health plans to ensure all chronic conditions are properly reported to avoid GAP periods.
• Monitors the referral process to ensure patient completed specialist visit and notes are received.
• Updates medication list, current problem list, and past medical history for every patient visit.
• Receives and makes patient calls to schedule / re-schedule appointments and provides instructions from primary clinician.
• Cultivates and supports primary care with timely communication, follow-up calls, and integration of patient information into the care plan.
• Participates in daily huddles with the clinical staff to review Medicare patients scheduled for the following day.
• Assists with the identification of "high-risk" patients based on chronic illnesses and special healthcare needs.
• Assists clinician with accurately documenting diagnoses in progress notes.
• Provides discharge instructions to patients, answers patient questions, and schedules follow-up appointments with PCP and in-house specialists, as needed.
• Assists clinician with medical assistant duties when needed.
• Performs other duties as assigned.

Last updated : 2024-07-11