Care Coordinator - Primary Care

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Position Summary:

The Care Coordinator (MA/CNA) supports HIA Health's Primary and Palliative Care programs by providing ongoing care coordination for medically complex, chronically ill, and high-risk patients. Responsibilities include chart preparation, patient outreach and follow-up, medication and care plan support, coordination of identified care needs, and other clinical and administrative activities that promote continuity of care and support the established plan of care.

Chronic Care Management and Longitudinal Care Coordination Provide proactive and responsive outreach to patients and caregivers to support continuity of care, ongoing needs, established care plans, preventive care, self-management, and access to appropriate services.

Coordinate care across Primary Care, Palliative Care, specialists, hospitals and clinics, residential facilities, pharmacies, home health agencies, DME suppliers, therapy providers, community resources, and other members of the care team.

Follow up on provider-directed care plans, patient needs, care gaps, referrals, tests, orders, equipment, services, and other care-coordination needs.

Support transitions of care following emergency department visits, hospitalizations, rehabilitation stays, or changes in care setting and facilitate appropriate follow-up with the care team.

Identify barriers, unmet needs, reported changes, or concerns and route or escalate matters requiring clinical assessment or judgment to the appropriate licensed nurse or provider.

Assist with identification and ongoing coordination of high-risk patients and support appropriate care-management workflows.

Document CCM and longitudinal care-coordination activities accurately, timely, and according to organizational requirements.

Patient, Caregiver and Care Team Communication Answer and respond to calls, messages, and other communications from patients, families/caregivers, facilities, providers, pharmacies, and healthcare professionals in a courteous and timely manner.

Promote timely access to appropriate care, patient education, self-management, shared decision-making, and continuity of care through collaboration with the patient and interdisciplinary care team.

Recognize time-sensitive or potentially urgent information and promptly route or escalate clinical concerns to the appropriate licensed nurse or provider.

Participate in interdisciplinary group (IDG), team, case-review, and organizational meetings as required; arrive prepared and provide needed handoff information before planned absences.

Medication and Care Plan Support Obtain current medication lists from patients, caregivers, facilities, pharmacies, discharge records, and other available sources and assist with medication-list reconciliation within authorized workflow.

Identify medication-list discrepancies, adherence barriers, reported medication concerns, or questions and route them to the appropriate licensed clinician or provider.

Follow up on provider-directed medication changes and routine refill requests as permitted by organizational policy and role authorization.

Reinforce provider- or care-team-directed instructions and support completion of established care-plan activities without independently changing the plan of care.

Orders, Referrals and Service Coordination Enter, transmit, track, and follow up on provider-directed orders according to organizational policy and role authorization.

Track and coordinate completion of laboratory testing, diagnostic testing, procedures, referrals, specialist appointments, and other ordered services.

Complete or assist with prior authorizations for medications, durable medical equipment (DME), procedures, and other services.

Initiate or assist with provider-directed DME, home health, home infusion, physical therapy, occupational therapy, and other services and follow through to completion.

Communicate unresolved barriers, delays, or incomplete services to the appropriate member of the care team.

Chart Preparation, Records and Preventive Care Support Prepare patient charts for Primary Care and Palliative Care provider visits and reconcile available information received from facilities, hospitals/clinics, health information exchanges, registries, and other sources.

Review and update available diagnoses, allergies, medication lists, immunizations, surgical/history information, and other chart elements as appropriate to role and workflow.

Verify…