Care Coordinator

Join our growing team!

Job Summary: The Care Coordinator is Responsible for implementation and oversight of a Care Coordination program for patients with chronic disease. The Chronic Care Coordinator will assist the Vice President of Quality Assurance, providers, site directors, CMO and CDO in remote and direct management of patients with chronic disease to ensure they receive the recommended routine health maintenance services, self-management support, assistance with adherence to evidence based treatment plan, education and follow-up. Will work with payers and EMR reporting tools to identify missed services and care opportunities in order to help patients achieve and maintain the highest level of health possible.

Required Skills/Abilities:

• Must maintain a high level of confidentiality.
• Strong computer and organizational skills are essential,
• The ability to multitask and respond to shifting priorities
• Meeting all required deadlines
• Ability to work independently while demonstrating the skill to work positively within the framework of a team.
• Working knowledge of Microsoft Office.

Education and Experience:

• Registered Nurse (RN) or Licensed Practical Nurse (LPN)
• Bachelors degree preferred
• Current licensure by the Maryland State Board of Nursing.
• At least two years experience in a primary care office.
• Experience in designing and implementing healthcare quality-improvement initiatives preferred.

Core Values:

• Commitment To Service
• Respect
• Quality
• Teamwork
• Patient Focus
• Integrity
• Accountability
• Caring & Compassion
• Professionalism
• Listening & Responding
• Safety
• AIDET

Job Related Competencies:

• Empathetic Outlook- The ability to perceive and understand the feelings and attitudes of others; the ability to place oneself “in the shoes” of another and to view a situation from their perspective.
• Attention to Detail- The ability to process detailed information effectively and consistently.
• Problem Solving- Identifies and analyzes problems weighing the relevance and accuracy of available information. Generates and evaluates alternative solutions and makes effective and timely decisions.
• Communicates Effectively- Developing and delivering multi-mode communication that convey a clear understanding of the unique needs of different audiences.
• Values And Ethics- Serving with integrity and respect in personal and organizational practices. Ensuring decisions and transactions are transparent and fair.
• Time Management- The ability to effectively manage one’s time and resources to ensure that work is completed efficiently.

Duties/Responsibilities:

Chronic Care Coordinator

• Provides basic short-term case management for complex and less-compliant medical patients.
• Tracks and follows up referrals to diagnostic testing, specialists, and health education (diabetes educators, dietitians, asthma educators, etc.), and to behavioral health specialists.
• Follows up on high risk hospital discharges to ensure continuity of care
• Coordinates with Patient Services Coordinators to ensure patients are connected to needed social resources.
• Follows up with patients with face-to-face and/or telephone contacts in order to facilitate compliance with self-management goals and care plan.
• Coordinates patient care with external disease management and/or care management organizations.

Management of chronic care registry.

• Tracks patients overdue for appointments, lab tests, eye examinations, etc.
• Follows up with providers and patients to schedule patients for medical care. Reminds patients of appointments and collects information prior to appointments.
• Runs and monitors registry reports at least monthly, or at the request of the VP of Quality, CMO, CDO, and site directors.
• Works with Clinical Informatics Coordinator/IT to ensure accuracy of data.
• Provides patient/ family education and instruction on issues of health maintenance and management of chronic conditions, provides patients/ families with educational materials for self management that are both paper and web based.
• Meets with the providers and site on a regular basis to prioritize care coordination needs for the practices.
• Completes all EMR/EDR and other documentation as required.
• Has a working knowledge of clinical microsystems.
• Uses clinical information to identify clinical areas for improvement.
• Assists in monitoring office processes to identify areas for improvement; recommends areas for improvement to the leadership/chronic care team, and assists in monitoring improvement initiatives within the office.
• Is an active member of the patient care team in the practice, and is included in treatment planning for patients.
• Regular, reliable attendance is a requirement of this job.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Note: As a healthcare organization that accepts Medicare/Medicaid - we are required to comply with all Federal mandates related to vaccines.
This requirement applies to all current and future Choptank employees.

Experience:

• Customer service: 2 years (Preferred)

Work Location: One location