Position Summary
The Care Coordinator ensures patient navigation is implemented by managing client caseloads, coordinating primary and specialty care, overseeing transitions of care, and collaborating closely with patient schedulers for timely follow up appointments. Care Coordinators facilitate conversations between interdisciplinary care team members regarding transitions of care as well as patient family members post provider visits.
Essential Duties and Responsibilities
Client Caseload Management
Assist with delivering quality care for patients with chronic conditions by providing critical insights and valuable data to Eventus care teams
Calling patient family members/POAs/caregivers to provide update post provider visits with clinical updates, answer any clinical questions
Provide day-to day support and supervision of care – ensuring labs, specialty notes, hospital and SNF records are available in EHR for provider review
Review patients’ medical history and information from all available information sources including both internal care team and outside providers and services
Performs medication reconciliation after a transition of care and summary of SNF/hospital stay
Create Chronic Care Management (CCM) and Behavioral Health Integration (BHI) care plans in conjunction with the billing/rendering providers to include medications, diagnosis, patient goals and interventions, care team members, barriers, and patient education. Ensures that care plans are updated as necessary
Ensuring that the recommendations of the care plans are being adhered to and that proper treatment and therapies are being followed.
Refers patients to needed services, such as specialist referrals
Calls patients/POAs/caregivers within 48 hours after a discharge from a hospital or SNF to check in and schedule a follow up visit
Organizational and Administrative Duties
Facilitate discussions with health care providers to discuss client Care Plans, transitions of care, medication reconciliation, family input and specialty referrals
Document client services in patients chart, including updated history and medication reconciliation from their transition of care, summary of information discussed during phone calls, etc.
Track client information and appointments in a confidential manner
Initiate outreach and missed appointment procedures, as necessary
Assist in disseminating tasks needed by providers to achieve quality metrics for value based care programs (I.e. depression screenings, BP readings and HGBA1C results)
Assist with coordinating physician visits with scheduling for LTC ACO and follow up appointments within 1 week for ACO reach patients after a transition of care
Track time spent in care coordination activities to document for chronic care management minutes
Ensure that all Medicare requirements of the CCM and BHI programs are being adhered to.
Other duties as assigned.
Education and/or Certifications
LPN degree or experienced certified MA with 5 years primary care experience
2 years minimum experience in the LTC/ALF setting
Care coordination experience preferred
Value based care experience ideal
Strong understanding of cultural competency with the target population
Competency with Excel, PCC, Matrix and Microsoft products with the ability to become proficient with company specific programs and software.
Interest in working with geriatric clients
Skills and Qualifications
Commitment to the mission of care coordination
Excellent communication and interpersonal skills with ability to speak concisely to clients, patient schedulers, families and other interdisciplinary care team members
Strong knowledge of geriatric population and patient navigation
Organized with confidential client material, appointment tracking, and caseloads
Desire to build relationships with patients, family members and other members of the health care team
Strong organizational and time management skills, and ability to prioritize tasks and meet deadlines
Professional verbal and written communication skills via phone, email, and other written correspondence
Friendly and professional demeanor.
Physical Requirements
While performing the duties of this job, the employee is regularly required to communicate with others, including the ability to express oneself and exchange information in what, at times, could be a stressful or high‑pressure environment.
The employee frequently is required to move about the office to access files, use office equipment, and to interact with others. The person must be able to sit or remain in a stationary position for extended periods of time to be able to work, communicate on the phone, utilize the computer, and interact with others.
About Eventus WholeHealth
Eventus WholeHealth was founded in 2014 to provide physician‑led healthcare services for residents and patients of skilled nursing and assisted living facilities. With our highly‑trained team of physicians, psychiatrists, nurse practitioners, physician assistants, psychotherapists, podiatrists, optometrists, audiologists, and support staff, our comprehensive, evidence‑based model provides collaborative interdisciplinary care with the seamless and vital integration of a wide range of specialties. Our differentiated approach not only empowers the facilities to reach their own goals and objectives but also ensures better patient outcomes. For more information, please visit www.eventuswholehealth.com.