Care Coordinator Reports to: Care Manager

Status: Full-time (Hourly/Non-Exempt)

Summary of Position: The Care Coordinator supports patients by coordinating care services and helping them follow their care plans. The role includes regular patient outreach, identifying and addressing gaps in care, coordinating services with providers and community resources, and documenting activities in the CareVitality platform and/or Electronic Health Record of the client.

The Care Coordinator works closely with providers, care managers, and internal teams to ensure continuity of care and support positive patient outcomes.

Responsibilities:

• Conduct monthly follow-up with patients by reviewing the patient-centered care plan based on physical, mental, cognitive, psychosocial, functional, and environmental assessments, as well as an inventory of available resources.
• Provide Chronic Care Management (CCM) patients with appropriate educational materials and resources to support health education, self-management, and lifestyle improvement.
• Identify patients with gaps in preventive health services and assist with scheduling required screenings or diagnostic tests with their providers.
• Review and update patients’ current allergy and medication profiles, assess adherence and potential interactions, and communicate concerns to the patient and providers as appropriate. Support patient self-management of medications within the Care Coordinator scope.
• Engage patients through monthly care plan reviews that promote healthy lifestyles, close gaps in care, and reduce unnecessary emergency department utilization and hospital readmissions. Coordinate care with patients, caregivers, primary care providers, specialists, community resources, behavioral health partners, and other health plan or system departments as appropriate.
• Document all care coordination activities in the or CareVitality platform and possibly the Electronic Health Record if requested by the client in accordance with CareVitality standards, including required time elements, and identify trends or opportunities for improvement based on patient, provider, and system interactions.
• Health Risk Assessments (HRA), Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Advanced Primary Care Management (APCM) may be incorporated into the role as program needs evolve.
• Escalate patients requiring reassessment, care plan revision, or higher level clinical intervention to the assigned Care Manager in a timely manner.
• Transitional Care Management Services may need to be provided in any given month as part of the scope of services
• Provide transportation assistance if needed
• Gathering patients consent for various care management and remote monitoring programs.
• Perform other duties as assigned.

Qualifications:

To successfully perform this role, an individual must be able to perform the essential duties satisfactorily. The qualifications listed below represent the knowledge, skills, and abilities required for the Care Coordinator role. Reasonable accommodations may be made for individuals with disabilities to perform the essential functions.

• Strong time management, focus, attention to detail, and communication skills, with the ability to demonstrate initiative and work independently.
• Ability to effectively multi-task while navigating multiple systems, including the electronic health record (EHR), Care Management and Remote Monitoring platforms, internet applications, email, and Microsoft Office (Outlook, Excel, Word, and PowerPoint).
• Experience accurately documenting time spent with each patient and monitoring assigned patient caseloads to ensure required time and program elements are met for Care Management programs, including CCM, RPM, BHI, PCM, TCM, APCM, and/or RTM.
• Positive attitude with a willingness to receive instruction, feedback, and guidance from a supervisor.
• Effective written and verbal communication skills
• Ability to be time efficient from 30 to 50 calls in a day if needed to get your work completed. You need to be comfortable outreaching to patients via phone and be focused on making outgoing calls to get your work completed. Prior call center experience is preferred.
• Proficiency in Microsoft Office applications, including Word, Excel, and Outlook

Education and Experience:

• The Care Coordinator can be a licensed practical nurse, licensed vocational nurse, or highly experienced medical assistant who provides these services.
• Further training or coursework in care coordination, care management, population health, or similar fields is desirable.

Language Skills:

Must have excellent interpersonal, oral and written English communication skills.

Reasoning Ability:

Ability to apply common sense and understanding to carry out written, oral, or diagram instructions. Ability to deal with problems involving multiple variables in standardized situations.

Physical Demands:

The physical demands of a Care Coordinator includes periods of sitting, standing, and walking throughout the day. Coordinators frequently use laptops and softphones for tasks such as typing, documentation, and reviewing electronic health records. Occasional bending and lifting of light materials may be necessary. The work environment has moderate noise levels that can vary depending on the location. Individuals with disabilities are provided reasonable accommodations to perform these essential functions.

Work Environment:

This position is primarily based in a work from home environment and may have you report into an office(s). The position involves regular interaction with clients, patients, and members of company at various locations. Duties performed outside of a traditional office setting, may require travel throughout assigned territories. Work is generally conducted in client or office settings, with varying conditions. The noise level in these environments is typically moderate.

Compensation and Benefits:

• Compensation: Please see the Care Coordinator Compensation Table for a range of compensations based on experience and education level
• Benefits: Health insurance, retirement plans, and paid time off
• Training: Training is paid at your hourly rate for the first 2 days, thereafter, you will be paid on performance per CPT Code completed or based on patient consent(s) you acquire