Care Coordinator Innovation Care Partners

Overview

Looking to be part of something more meaningful? At Honor Health, you’ll be part of a team, creating a multi-dimensional care experience for our patients. You’ll have opportunities to make a difference. From our Ambassador Movement to our robust training and development programs, you can select where and how you want to make an impact. Honor Health offers a diverse benefits portfolio for our full-time and part-time team members designed to help you and your family live your best lives.

Visit  to learn more. Join us. Let’s go beyond expectations and transform healthcare together. Honor Health is one of Arizona’s largest nonprofit healthcare systems, serving a population of five million people in the greater Phoenix metropolitan area. The comprehensive network encompasses six acute-care hospitals, an extensive medical group with primary, specialty and urgent care services, a cancer care network, outpatient surgery centers, clinical research, medical education, a foundation, an accountable care organization, community services and more.

With nearly 17,000 team members, 3,700 affiliated providers and close to 2,000 volunteers dedicated to providing high quality care, Honor Health strives to go beyond the expectations of a traditional healthcare system to improve the health and well‑being of communities across Arizona. Learn more at

Job Summary

The Care Coordinator I collaborates with the primary physician and other health care team members in the development of patient centered goals and actions, ensuring the formulation of a realistic and definitive goal that represents the total care needs and resources of the patient/client and family. The Care Coordinator acts as patient advocate through the continuum and is available to the physician, patient and family as a resource to facilitate communication.

Responsible for providing coaching and care coordination to assigned patients to ensure effective transitions as patients move through the health care continuum to include the ambulatory care setting, hospital, home environment and skill nursing facilities. Serves as an embedded care resource with focus on the health and wellness and care coordination needs of the patient population.

• Coaches and guides patients and their caregivers in addressing critical issues and self‑management tasks to assist patients in their recovery efforts. Utilize active listening, behavioral motivational interviewing, guided care goal setting, and home visits to ensure face‑to‑face communication and relationship building. Ensures accurate and complete documentation is recorded for every patient encounter.
• In conjunction with clinical practitioners such as home health RNs, doctors, physician assistants, etc. coordinates and reviews patients’ progress and ability to manage health care issues. Strives to meet goals in educating and empowering the patients and their caregivers in their health care in order to prevent the need for additional resources and possible hospital admissions. Performs outbound calling, home visits, appointment scheduling as necessary.
• Assists patients with their medication reconciliation, coordination of post‑discharge home care needs, self‑management support, follow‑up care, supportive care, advanced care planning, community resources, and long‑term planning needs. Reports patients’ compliance/non‑compliance with medical care instructions to appropriate clinical staff. Communicates professionally and using all modalities (email, technology, written, and verbal) with clinical team, patients, and caregivers in a way that is clear and concise.
• Ensures safe handoff of care for hospitalized / post‑acute care patients from Transitional Care Managers to Care Coordinators. Coordinates follow‑up care with PCP/ Specialists regarding outpatient follow‑up appointment and plan of care. Coordinates care with internal and external providers and healthcare team members involved in the care. Builds and maintains working relationships with patients and their caregivers and other health care partners.
• Maintains and manages their caseloads working independently with a minimum of…