Primary Function-

The Care Coordinator will coordinate team-based care to provide health services and education to patients and families through effective partnerships with Kidwell practices, community resources and medical professionals. Provides Care Coordination in the Kidwell practice setting by utilizing critical thinking skills and social worker expertise to optimize patient outcomes amongst designated populations within the practice. 

Works with patients and families to ensure both behavioral and psychosocial needs are met. Works with Kidwell practices to address gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk. Addresses gaps in care and promotes timely access to appropriate care, increasing the utilization of preventative care and healthy behaviors to improve the health of the population at risk.

Essential Functions-

Assist with, and/or promote, the identification of patients in the practices with special health care needs by reviewing appropriate registry reports. Monitors chronic/preventive patient registries/lists and Gap in Care reports to assist in getting patients the appropriate appointments and/or interventions.

Initiate family contacts: create ongoing processes for families to determine and request the level of care-coordination or care management support they desire for their child/youth or family member at any given point in time. Identify patient and family needs and unmet needs, strengths and assets. 

As a member of the care team, monitor patient care plans with family/youth/team (emergency plan, medical summary and action plan as appropriate). Contacts identified patients for preventative services and/or pre-visit forms.

Care management coordination of non-clinical services such as, transportation, follow up on referrals, etc. Follow up on patient hospitalizations and ER visits. 

Serve as contact point, advocate and informational resource for family and community partners/payors. Referrals to child protective services and appropriate agencies for domestic violence. Research, find and link resources, services, and supports with/for the patient/family. Assists with getting insurance coverage for patients without insurance.

Coordinate inter-organizationally among family, the medical home, and involved agencies. Identifies community resources and tracks select community and specialty referrals. Connect to and understand community resources, i.e., WIC, food stamps, DME providers, advocacy groups, schools, financial assistance, counseling, anger management classes, special needs camps or inner-city camps. 

Promotes/documents Quality Improvement Cycles. Responsible for generating required data as appropriate.

Facilitates the NCQA process at the offices working in close collaboration with the VBSO and the Medical Home liaison.

Qualifications-

High School Diploma

Scheduling experience preferred