The Care Coordinator is a core member of the care team, responsible for supporting and coordinating the overall health of patients with a focus on chronic conditions, preventative care, and healthy behaviors.
Essential Functions
Communicates to patients the purpose of the program and the impact it may have on their wellbeing.
Helps patients identify social determinants of health that affect their overall health and develop health and social management plans and goals.
Educates the patient on the proper use of the emergency room and provides information for alternatives.
Assists patients in understanding care plans and instructions. Motivates patients to be active and engaged participants in their health and overall wellbeing.
Develops a comprehensive individualized plan of care and targeted interventions incorporating the patient’s preferences and SMART goals.
Communicates effectively with the patient’s care team/PCP to exchange information about the patient and give updates on progress with self‑management support services.
Ensures age‑applicable health assessments/screenings are completed timely and documented in the electronic health record appropriately.
Continually develops knowledge and understanding of community resources, NorthShore services, and programs offered.
Completes transitions of care for ER/IP visits for patients within 72 hours of discharge and documents findings appropriately in the patient’s electronic health record.
Closes the loop on all external referrals and obtains outside records and results.
Addresses gaps in care and documents results in the patient’s electronic health record.
Assists with patient/provider requests for durable medical equipment, home health services, FMLA requests, etc.
Completes glucose testing, CGM placements, basic vitals, and other tests assigned by management.
Provides follow‑up to patients to find out if they are meeting goals and how they are managing health issues, celebrates successes, and provides suggestions to overcome barriers to care.
Maintains top quality proficiencies across all training areas in daily work.
Attends meetings and training sessions as required.
Executes other assigned tasks as requested by management.
Competencies
Planning and strategic foresight
Responsible decision making and problem solving
Integrity and accountability
Innovation and creativity
Adaptive and flexible
Leadership, teamwork, and conflict resolution
Professionalism and work ethic
Empathy
Required Role Qualifications
Minimum required education per state of Indiana/HRSA
1 year of care coordination experience
Community Health Worker Certification within 1 year of hire
Valid CPR certification
Preferred Role Qualifications
Two years of experience working within a healthcare setting.
Certified/Registered Medical Assistant, Licensed Practical Nurse, Advanced Practice Nurse, or Registered Nurse licensing
<>Bilingual preferred
Required Skills
Analyze situations and solve problems at strategic and tactical levels
Excellent interpersonal and customer service skills
Comprehend, interpret, and apply applicable laws, guidelines, regulations, ordinances, and policies
Understand organizational hierarchy, jobs, qualifications, compensation practices, and administrative practices
Plan and organize
Critical thinking and problem solving
Maintain composure and emotional intelligence
Ethical reasoning and decision making
Strong attention to detail
Responsive to feedback
Excellent verbal and written communication skills
Time management, prioritization, and sense of urgency
Proficient with Microsoft Office Suite or related software
Physical Requirements
Sitting
Walking
Standing
Bending
Squatting/Crouching
Climbing
Kneeling
Twisting/Turning
Hand dexterity/Fine motor manipulation
Lifting 0–50 lbs
Lifting 50+ lbs
Carrying 0–50 lbs
Carrying 50+ lbs
Pushing 0–300 lbs
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