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.
Call patient family members/POAs/caregivers to provide updates post provider visits, answer clinical questions.
Provide day‑to‑day support and supervision of care – ensuring labs, specialty notes, hospital and SNF records are available in the EHR for provider review.
Review patients’ medical history from all available information sources, both internal and external providers.
Perform medication reconciliation after a transition of care and summarize SNF/hospital stay.
Create Chronic Care Management (CCM) and Behavioral Health Integration (BHI) care plans with billing/rendering providers, and keep care plans updated.
Ensure recommendations of care plans are adhered to and proper treatments and therapies are followed.
Refer patients to needed services such as specialist referrals.
Contact patients/POAs/caregivers within 48 hours after discharge from a hospital or SNF to check in and schedule follow‑up.
Facilitate discussions with healthcare providers about client care plans, transitions of care, medication reconciliation, family input, and specialty referrals.
Document client services and updated history in patient charts, including medication reconciliation from transition of care and summaries of phone calls.
Track client information and appointments confidentially.
Initiate outreach and missed appointment procedures as needed.
Assist in disseminating tasks needed by providers to achieve quality metrics for value‑based care programs (e.g., depression screenings, BP readings, and HbA1c results).
Coordinate physician visits and scheduling for LTC ACO and follow‑up appointments within one week for ACO reach patients after transition of care.
Track time spent in care coordination activities to document chronic care management minutes.
Ensure all Medicare requirements of CCM and BHI programs are adhered to.
Other duties as assigned.
Education and Certifications:
LPN degree or experienced certified MA with 5 years of primary care experience.
2 years minimum experience in LTC/ALF settings.
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 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, families, and healthcare team members.
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:
Must be able to communicate with others, including expressing oneself and exchanging information in stressful or high‑pressure environments.
Frequently required to move about the office to access files, use office equipment, and interact with others; must be able to sit or remain in a stationary position for extended periods of time while working, speaking on the phone, utilizing the computer, and interacting 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 a highly‑trained team of physicians, psychiatrists, nurse practitioners, physician assistants, psychotherapists, podiatrists, optometrists, audiologists, and support staff, our comprehensive, evidence‑based model delivers collaborative interdisciplinary care with the seamless integration of a wide range of specialties. Our differentiated approach empowers facilities to reach their goals and improves patient outcomes. For more information, please visit www.eventuswholehealth.com.