Patient Care Coordinator(Case Manager)

Provides coordinated care to patients with chronic care conditions and or behavioral health needs by developing, monitoring, and evaluating interdisciplinary care. The Patient Care Coordinator coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient- and family-centered.

Essential Duties

1. Assess needs and provides a coordinated, strategic approach to detect early and effectively manage the patient population.
2. Implement an effective internal tracking system for identified patients.
3. Aid in determining gap assessment needs.
4. Coach patients/families toward successful self-management of their chronic disease.
5. Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.
6. Aid in Annual Wellness Visit coordination.
7. Assess patient and family’s unmet health and social needs.
8. Provide effective communications to improve health literacy. Identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.
9. Develop a care plan based on mutual goals with the patient, family, and provider’s emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.
10. Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.
11. Promote healthy behaviors in all populations and ensure navigation assistance with community resources.
12. Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists.
13. Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
14. Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources. Respectfully resolve patient/family concerns.
15. Ensure effective tracking of test results, medication management, and adherence to follow-up appointments. Maintain accurate notes and records.
16. Develop systems to prevent errors (e.g., effective medication reconciliation).
17. Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed.
18. Provides mentoring/coaching of other population health and care coordination team members.
19. Attend and actively participate in all Care Coordination related training and meeting activities
20. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
21. Ensures no injuries to self or others by following safe work practices and policies. This includes, but is not limited to security and safety, understanding of MSDS, equipment, infection control, fire, disaster, safe lifting and body mechanics.
22. Ensures self-compliance with organization policies and procedures, as well as labor agreements.
23. Ensures the interface with team members and other support groups is conducted in a courteous and efficient manner conducive with the organization’s values.
24. Conducts self in a professional manner and ensures personal appearance meets the standards necessary to perform the job function and while representing the organization.
25. Ensures that additional accountabilities as may be required by management

• Works with all area resources in relation to improved patient outcomes.

• Participates in facility Performance Improvement (PI) program, including development and review of internal department quality monitors, tracking, and reporting quarterly PI findings in a timely manner, and/or reporting all patient quality issues
• RN, LPN, or Social Worker required.

• Previous Care Management or Case Management experience preferred.

• Must be competent in interpersonal relations.

• Must possess the ability to be flexible and prioritize work tasks, etc.

• Must have ability to work independently with minimal supervision.

• Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.

• Must be able to speak and write articulately.