Job Description

SouthCoast Health Is Looking For A Full-time Patient Care Coordinator

The role of the Patient Care Coordinator is to assist the Care Team (Provider, nurse, medical assistant) by:

• Coordinating care to patients on the providers daily schedule and by proactively managing and;
• Coordinating care for patients not on the schedule, so as to offer complete preventive care for all patients who are part of the assigned panel.

Coordinate services for all patients who are part of the assigned panel, especially those with serious, complex or chronic health problems or with psychosocial issues.

Provide advocacy, information and referral services to patients and families to address their medical and psychosocial needs.

Qualifications:

• Ability to appropriately conduct assessments and assistance techniques.
  
• Knowledge in health information management by appropriately charting patient data.
• Knowledge and demonstrated proficiency in performing clinical skills.
• Knowledge of medical charge reporting/records.

Responsibilities:

• Review provider schedules and individual patient charts and assist the care team in coordinating care for visits and for future healthcare needs.
• Handle non-appointment related calls from patients that involve care coordination, registry follow-up, etc.
• Provide an effective communication link between patient and medical staff, including relaying messages from providers, gathering information from patients for providers, etc. Participate in clinical team huddles as needed.
• Use registry and other information to inform care team members of preventive care required for each patient seen each day.
• Ensure that all patients are tracked for follow-up and reporting.
• Ensure that pertinent data and tracking information is entered into the PM and or EMR systems.
• Regularly review registry information for assigned panel of patients and arrange for care needed to proactively coordinate healthcare needs.
• Coordinate with the medical staff to ensure that case management services are provided to patients with complex medical and/or psychosocial problems.
• Work with the medical staff to develop, implement and carry out programs in chronic disease management for patients, with such problems as diabetes, asthma, congestive heart failure, hypertension and depression, based on chronic disease management model.
• Assist in coordination of care with pharmacies, insurance companies and other providers in the community. Ensure that information goes when and where it is needed.
• Ensure that disease and other registry data entry is up to date and use registry reports to organize plan of care for complex patients on assigned panel.
• Participate in team decisions regarding data requirements for pro-actively managing the team's panel.
• Use and update the directory of resources in the service area to meet basic health and human needs. Be efficient at using the resources available within the practice and the community.
• Act as a back-up to other Care Coordinators or to other Care Team members as needed.

Education/Experience:

High School Diploma or GED required. Graduate of an accredited school of practical/vocational nursing program highly preferred or MA diploma/certification highly preferred but not required.

Minimum of two years clinical/clerical experience, preferably in a hospital or outpatient practice setting working with complex medical needs.

Benefits:

Health, HSA, FSA, dental, vision, life, long term disability, 401(k) with employer contribution & supplemental insurance. PTO, holidays, jury duty and bereavement leave.

EEO, DFW, MFVD

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