The Care Coordinator is the “link” to ensure a continuity in coordination of patient care through his/her collaborative interaction with all the community relationships involved in that care – including but not limited to – the labs, hospitals, patients themselves, and patient’s healthcare plan (i.e. Medicaid, Managed Care Plus).
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Collaborative Partner Coordination of Services:
- Follow-up consistently on transitional care for patients.
- Ensure appropriate frequency of patient visits to maintain for the team and the patient a proper continuum of care.
- Coordinates continuity of patient care with external healthcare organizations, facilities, and payers including the process of hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
- Becomes knowledgeable in and keeps updated on Pillars Community Health’s payer contracts as they relate to patient access, referrals, pre-authorizations and clinical indicators measures.
Patient Centered Care:
- Manage potential risks and liabilities within the health center to minimize risk of errors, accidents and other adverse incidents.
- Pay close attention to EMR system notes and alerts, routing information appropriately to correct team members for quality patient care.
- Assist in management of high-risk patient care including management of patients with multiple co-morbidities or high-risk for readmission to a hospital setting, including a registry.
Continuous Quality Improvement:
- Be a voice for strictly adhering to the Pillars Community Health Quality Improvement Plan, and work with the staff to assure compliance.
- Work closely with the QI Manager to assure HIPAA compliance in the sharing of PHI with collaborative partners on behalf of patient.
- Participate in training programs that focus on the components of the Quality Program.
- Graduation from an accredited college or university with a background in health-science, biology, anatomy & physiology, public health, behavioral science or other similar degree
- Case management experience preferred
- Public Health educational focus
- Medical Assistant background
- FQHC background or experience in outpatient setting highly preferred
- Meets company health & immunization/vaccination requirements
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