Care Coordinator

Job Summary

Responsible for direction of patient care in the outpatient care setting. Consulting with staff, providers and Nurse Manager on nursing problems and interpretation of clinical policies to ensure patient needs are met. Maintains performance improvement activities within the department and participates in CQI activities. Assist Nurse Manager, providers and staff in the coordination of care for the patient population. This care coordination includes assisting patients with establishing appointments outside the Patient Centered Medical Home (PCMH), sending referrals, establishing co‑management agreements and tracking the course of the patient’s care to ensure proper follow‑up, and helping to remove any barriers to care.

• Consult with other departments, as appropriate, to collaborate in patient care and performance improvement activities
• Participate with care team in coordination of patient care according to Priority Health Care policies and procedures
• Effectively facilitate daily huddle for care coordination and continuity of patient care
• Manage patient testing, notify provider of imaging/x‑ray results and communicate provider instructions to the patient; review lab results in conjunction with provider review
• Effectively build and manage partnerships/relationships with outside sources to promote continuity of care
• Coordinate and direct patient care to ensure patients’ needs are met and clinical policies are followed
• Communicate with local hospitals, specialists and insurance plans to ensure proper follow‑up after hospital admission, emergency department visit, or consultation
• Maintain accurate and continued nursing documentation including patient history, condition, treatment, responses and assessment of changes
• Provide recommendations and/or complete evaluations as indicated, and submit in a timely manner to the Nurse Manager for review
• Communicate appropriately and clearly with Nurse Manager, providers, and other team members

• Management of high‑risk population care
• Assist patients with in‑house referrals within two days
• Educate patient population regarding community resources and ensure proper coordination with CMO, providers, staff, and outreach workers to eliminate barriers to care for the patient population
• Contact patients in pre‑visit preparation before upcoming appointments
• Follow up with patients/families who have not kept important appointments
• Assist patients in promotion of self‑management tools
• Adequately assess and reassess patients with chronic diseases; utilize appropriate disease‑management techniques; educate patient and family regarding disease process
• Formulate an individual plan of care, as indicated, and evaluate plan for effectiveness
• Formulate a teaching plan based on identified patient learning needs, and evaluate effectiveness of learning as appropriate
• As directed by provider, perform waived testing; communicate results to provider and take appropriate action as directed by providers or standing order
• Assist providers and team members with patient procedures
• Communicate routinely with patients to ensure compliance with visits and medications as appropriate to disease
• Interact professionally with patient and family; involve patient and family in the formation of the plan of care
• Treat patients and families with respect and dignity; identify and address psychosocial needs of patients and family; practice good guest relations

• Identify hospital admissions, hospital readmissions, emergency room visits and ensure proper follow‑up of patients
• Execute and track all patient testing and referrals for assigned location in accordance with PHC policies and procedures
• Maintain ongoing tracking and appropriate documentation on referrals to promote team awareness and ensure patient safety; ensure referral tracking is completed electronically through the electronic medical record

• Stay up to date on community resources that are available to patients to promote holistic health and promote patient involvement in plan of care
• Make decisions that reflect professional knowledge of facts, knowledge of disease/surgical conditions, care…