Patient Care Coordinator
Provides coordinated care to patients with chronic care conditions and or behavioral health needs by developing, monitoring, and evaluating interdisciplinary care. The Patient Care Coordinator coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a shared goal model within and across settings to achieve coordinated high-quality care that is patient- and family-centered.
Essential Job Functions:
- Answers phones, greets patients and families
- Assess needs and provides a coordinated, strategic approach to detect early and effectively manage the patient population
- Implement an effective internal tracking system for identified patients
- Aid in determining gap assessment needs
- Coach patients/families toward successful self-management of their chronic disease
- Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care
- Aid in Annual Wellness Visit coordination
- Assess patient and familys unmet health and social needs
- Provide effective communications to improve health literacy
- Identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required
- Develop a care plan based on mutual goals with the patient, family, and providers emergency plan, medical summary, and ongoing action plan, as appropriate
- Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed
- Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time
- Promote healthy behaviors in all populations and ensure navigation assistance with community resources
- Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists
- Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
- Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources
- Respectfully resolve patient/family concerns
- Ensure effective tracking of test results, medication management, and adherence to follow-up appointments
- Maintain accurate notes and records
- Develop systems to prevent errors (e.g., effective medication reconciliation)
- Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed
- Provides mentoring/coaching of other population health and care coordination team members
- Attend and actively participate in all Care Coordination related training and meeting activities