PURPOSE STATEMENT:

Responsible for assisting in coordinating team-based care, to provide health services to individuals, through effective partnership with patients, their caregivers/families, community resources and members of the Care Team.

ESSENTIAL FUNCTIONS

· Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.

· Work with RN’s and payers to plan and monitor patient care.

· Assess patient’s unmet health and social needs.

· Facilitate patient access to appropriate medical and specialty providers.

· Educate patient and family/caregiver(s) about relevant community resources.

· Facilitate and attend meetings between care team, payers, and community resources, as needed

· Assist with the identification of “high-risk” patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR)

· Follow up and monitor patients via payer work lists to assist in scheduling and following patient chronic care diagnosis.

· Attend all Care Coordinator training courses/webinars and meetings

· Display knowledge of preventative health requirements

· Maintain regular and predictable attendance

· Perform other essential duties as assigned

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

· Current Certified Medical Assistant certification or licensed practical nurse

Two years’ experience as a CCMA or LPN required

· BLS

· Previous experience in caring for chronic disease patients preferred

· Two years’ experience in clinical or community health setting preferred

· Previous Care Coordination, Case Management or Home Health experience preferred

· Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the hospital/clinic.