Job Overview
The Care Coordinator II (CCII) plays a crucial role in supporting, managing and coordinating a patient's care plan. The CCII Lead acts as a liaison between the patient or caregiver, the primary care team and external partners to ensure seamless communication and timely access to care. Primary responsibilities include working in tandem with the primary care team to coordinate healthcare services. The CCII assures continuity of care is maintained and optimized for the patient and their care team’s well‑being.
Note: This position is mostly remote with the need to go into the office on occasion.
Actively supports an assigned panel of patients by providing timely complex care coordination for patients with physical and behavioral health care needs.
Escalates concerns to primary care team according to protocols.
De‑escales high‑stress situations and complaints received and forwards to primary care team/leadership as appropriate.
Coordinates referrals for supportive services, labs, diagnostics or other coordination of care needs as requested by the primary care team based on insurance, location, patient preference and order type.
Schedules patient visits for assigned panel of patients based on urgency, geographic location, appointment type, provider availability and frequency of visit standards.
Clinical Support
Authorize prescription refills for non‑controlled drugs if approved by clinician.
Provide pharmacy support including verbal orders, when appropriate, to expedite or clarify medication fulfillment.
Provide primary care coordination support to assigned panel of patients with physical and behavioral health care coordination needs.
Responsible for meeting with DME vendors to maintain relationships and problem‑solve.
Manages DME orders, ensuring charting and all documentation requirements are met.
Supports providers and patients with DME appeal process and follows up to make sure DME is delivered.
Coordinates complex care with support services and community partners, including but not limited to home health, hospices, according to the patient's plan of care.
Create/update patient charts and enter insurance, demographic, medication, diagnosis and social information in the EHR, assuring accuracy, completeness and compliance with policies and procedures.
Effectively coordinates care for patients with chronic and serious illness with internal and external stakeholders.
Coordinate with the care team to ensure consideration is given to unique needs in integrated planning and that physical and behavioral health care plans are timely and effective.
Develop working partnerships with patient, family, caregiver and community care providers, payors regarding patient needs and care plans.
Assist with transitions in care from multiple settings to ensure continuity of care and address urgent issues appropriately. Works with care team to ensure transition in care visits are scheduled according to protocols.
Updates hospice and home health regarding patient hospitalizations and transitional care visits.
Act as a consult to other teams and roles (external and internal) for geographically specific resources.
Assist patients, caregivers and families in establishing/engaging with providers by coordinating appointment and transportation, as needed.
Arrange family and/or caregiver attendance at appointments and interpreters as required.
Provides information about appointments, care plans, medications, referrals, prior authorizations, DME requests.
Identify risk factors and service needs that may impact patient outcomes and address appropriately.
Utilize a trauma‑informed approach to provide patient‑centric physical and behavioral health care and support including a person‑centered approach to communication, education and care planning.
Assist patients with moving through the continuum of care based on clinical/medical/behavioral health needs by collaborating with the PCP, Primary Care Clinical Team (PCT), palliative care and hospice teams.
Use motivational interviewing to coach patients toward improved physical and behavioral health care behaviors and self‑management.
Coordinate clinicians' diagnostic and lab orders, including lab and diagnostic testing, medical supplies and equipment.
Provides timely outreach providing education, follow‑up on labs or diagnostics or clinical instructions from a member of the primary care team.
Implement physical and behavioral health care coordination plan in collaboration with the patient’s care team, including patient, family, caregiver, internal team members, as well as external providers, case workers and other relevant parties.
Documentation and Other Duties
Compile and document all patient interactions and support activities in an appropriate and timely fashion to maintain patient's medical record.
Participate in quality and organizational process improvement activities and teams when requested.
Take initiative in proactively assisting teammates when work volumes are high or back‑up is needed.
Experience and/or Education
Minimum 4 years’ experience in a healthcare setting, including experience with medical records system.
Knowledge, Skills and Abilities Required
Knowledge
Advanced knowledge of basic healthcare language, including medical and/or behavioral health terminology, basic patient care and community resources.
Demonstrates advanced knowledge of barriers to care such as language, cultural factors, transportation, ability to self‑manage and psychosocial issues and bring those to the attention for the care team.
Knowledge of HIPAA privacy rules and regulations.
Advanced knowledge of basic conflict management and de‑escalation techniques.
Skills and Abilities
Leadership skills, including the ability to organize work and train/mentor others.
Participate in work‑related continuing education when offered or directed.
Excellent customer service skills, including the ability to interact professionally, patiently and courteously with staff, patients, families and vendors over the phone and in‑person.
Employs motivational interviewing, healthcare teaching and coaching skills or has the ability to learn.
Advanced organizational skills, plus the ability to manage multiple tasks and timelines in a high‑stress environment. This includes the ability to: prioritize tasks, manage telephone calls with a professional demeanor, problem‑solve and stay focused; work independently and collaboratively; use good judgment, personal initiative and discretion to perform job responsibilities; take initiative and utilize innovative techniques and ingenuity; facilitate group discussion or case review; employ critical thinking and draw conclusions from conversations and written or computer‑generated material; communicate effectively with diverse staff and patients, their families and caregivers; accept direction and feedback; tolerate and manage stress; perform repetitive finger and wrist movement; hear and speak clearly.
Advanced computer application skills, including MS Windows, Word, Excel and Outlook.
Detailed understanding of electronic medical record systems and the ability to integrate updates to those workflows on a regular basis.
Working Conditions
Work Environment(s): Indoor/Office; Community; Facilities/Security; Outdoor Exposure.
Member/Patient Facing: No; Telephonic; In Person.
Hazards: May include, but not limited to, physical and ergonomic hazards.
Equipment: General office equipment.
Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home.
Benefits
We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits‑eligible employees qualify for benefits beginning on the first of the month on or after their start date. Housecall Providers offers medical, dental, vision, life, AD&DD, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre‑tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits‑eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non‑benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.
Equal Opportunity Statement
We are an equal opportunity employer. The organization selects the best individual for the job based upon job‑related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.