Job Summary The Care Coordinator collaborates with the primary physician and other health care team members in the development of patient centered goals and actions, ensuring the formulation of a realistic and definitive goal that represents the total care needs and resources of the patient/client and family. The Care Coordinator acts as patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication. Responsible for providing coaching and care coordination to assigned patients to ensure effective transitions as patients move through the health care continuum to include the ambulatory care setting, hospital, home environment and skill nursing facilities. Serves as an embedded care resource with focus on the health and wellness and care coordination needs of the patient population.
Coaches and guides patients and their caregivers in addressing critical issues and self-management tasks to assist patients in their recovery efforts. Utilize active listening, Behavioral Motivational Interviewing, guided care goal setting, and home visits to ensure face to face communication and relationship building. Ensures accurate and complete documentation is recorded for every patient encounter.
In conjunction with clinical practitioners such as home health RNs, doctors, physician assistants, etc. coordinates and reviews patients' progress and ability to manage health care issues. Strives to meet goals in educating and empowering the patients and their caregivers in their health care in order to prevent the need for additional resources and possible hospital admissions. Performs outbound calling, home visits, appointment scheduling as necessary.
Assists patients with their medication reconciliation, coordination of post-discharge home care needs, self-management support, follow-up care, supportive care, advanced care planning, community resources, and long-term planning needs. Reports patients' compliance/non-compliance with medical care instructions to appropriate clinical staff. Communicates professionally and using all modalities (email, technology, written, and verbal) with clinical team, patients, and care givers in a way that is clear and concise.
Ensures safe handoff of care for hospitalized / post-acute care patients from Transitional Care Managers to Care Coordinators. Coordinates follow-up care with PCP/ Specialists regarding outpatient follow-up appointment and plan of care. Coordinates care with internal and external providers and healthcare team members involved in the care. Builds and maintains working relationships with patients and their care givers and other health care partners.
Maintains and manages their caseloads working independently with a minimum of direction, anticipate and organize work flow, work with a high volume caseload, and deal with rapidly changing priorities. Works collaboratively with HonorHealth staff, social service organizations and community resources, as needed, to meet each patient's needs. Maintains a working knowledge of applicable laws and regulations, government (Medicare, Medicaid, SSI, and SSDI) and insurance benefits. Performs other duties as assigned.
Internal Number: 2018-13124
Let’s transform healthcare together.
Every day, we bring patients convenient, coordinated access to healthcare while providing meaningful service to our community.
Join us and you will:
Develop professionally and achieve your career goals
Enrich your life with a focus on wellness
Enjoy a compassionate, caring culture with outreach to our local communities
Support the well-being of you and your family with a diverse portfolio of benefits
Welcome to HonorHealth.
We are a non-profit, local healthcare organization known for community service and outstanding medical quality. Our organization encompasses five acute care hospitals with approximately 10,500 employees and 3,100 volunteers, urgent care centers, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.