Outpat Care Coor

Description

Job Location:

Greenfield, MA

Job Schedule:

Full Time Standard Hours
40 / Non-exempt

Job Shift Shift 1

Reports to:

Program Manager, Care Management Shift Details Mon-Fri

Job Description Summary The Outpatient Care Coordinator is responsible for coordinating care for a population of patients with the goal of improving/maintaining outcomes. Major responsibilities/accountabilities include providing outreach and coaching to patients on self-care in a professional, respectful manner; linking patients to community resources, providing social care management, closing gaps in care through use of standing orders/protocols, managing transitions of care, and accurately and efficiently entering clinical data.

The Outpatient Care Coordinator is responsible for proactively helping patients and their families navigate and access health and community services while adopting healthy behaviors. Works to promote, maintain, and improve the health of patients and their families by providing coaching and social support. They will work collaboratively with providers and other health team members along the patient’s continuum of care to promote and maximize care coordination and patient satisfaction and are available to patients and families for care coordination/coaching through face-to-face visits, home visits, if necessary, as well as telephonic interactions.

Follows up with patients that have been in the Emergency Department/Inpatient to facilitate PCP follow up and identify unmet needs, under the direction of the Nurse Care Manager. Maintains clear, concise, objective and accurate documentation of patient encounters. Conducts Health Risk Assessments and Orientations to the practice and refers patients appropriately to the Nurse Care Manager. Screens/Identifies/Outreaches to patients to assure needs for preventive care and disease management are met.

Assesses/addresses social determinants of health/barriers to care. Develops and implements a personal development program to ensure continuing professional growth. Observes all health and safety requirements.

Adheres to system and department compliance policies, and all applicable laws/regulations.

Performs other additional duties as assigned.

Job Requirements Develops and maintains excellent working relationships with patients, providers and their practice staff, as well as other key stakeholders along the continuum (e.g., Inpatient, Post-Acute)
Quality Management:
Utilizes registries as well as standing orders to proactively identify and outreach to patients that need preventive screenings/chronic disease testing. Assists patients in scheduling appointments and tracking until the results are received. Collaborates with the care team to track, monitor and report on specified disease-related and patient tracking measures.

Transitions of Care:
Provides outreach calls, per protocol, to patients that have been discharged from the hospital or the emergency room. Reviews discharge instructions, ensures follow up appointments are made, screens for care management.

Promotes timely access to appropriate care while increasing the utilization of preventative care, managing referrals, transitions-in
-care, and reducing emergency room utilizition and hospitalization.

Care Coordination:
Provides ongoing support and coaching to a subset of patients needing care coordination, resource linkage, self-management support. This includes assisting with medication adherence as well as assessing/addressing barriers to care.

Links patients to community resources and tracks to ensure services are in place.

Works in collaboration with the Nurse Care Manager to ensure care coordination activities are provided to maximize outcomes for the patient.

Prescreens patients for complex care management utilizing a Health Risk Assessment.

Provides clear, concise documentation in the patient’s Medical Record, as well as the Care Management system.

Performs home visits, when necessary, to a subset of patients.

Continuously expands knowledge and understanding of community resources and services, public health prevention, and evidence-based intervention programs provided.

Enters necessary orders based on standing order protocols, within scope of practice.

Skills/

Competencies:

Required:

Excellent written and verbal communication and interpersonal skills are a must. Capacity to work closely with patients, providers and their office staff and managed care plans. Strong organizational and prioritization skills. Attention to detail and able to…