Works collaboratively with providers and clinical associates to support patients with chronic conditions and/or complex needs according to guidelines established by the primary care. Facilitates communication, coordinate services, address barriers, and promote optimal allocation of resources while balancing clinical quality and cost management.
A Care Coordinator works primarily in the ambulatory setting, and is a member of the physician led interdisciplinary team. Care Coordinator understands and adheres to established best practice care management standards of care: screen, assess, plan, and facilitate. Care Coordinator understands and coordinates care using evidence based clinical guidelines for chronic disease management.
DUTIES AND RESPONSIBILITIES:
1. Documents in chart the appropriate patient history
2. Provides patient care by giving clear direction to the patient, address patient concerns regarding care.
3. Support Chronic Disease Management and Patient Care Needs:
- Respond to provider referrals and/or identify patients who meet established criteria for care management (e.g. HgA1c > 8, elevated LDL and/or blood pressure, Mental Health Integration referral, complex needs)
- Assess patients’ readiness to change and family resources for support
- Monitor compliance with plan of care and problem solve barriers to patient self-management
- Provide support for patient and family issues, resource needs, and answering general healthcare questions
- Do ADL assessment and home safety assessments based on patient interview
- Obtain provider order for home health services for monitoring in home if medical necessity
- Teach patient how to self-monitor conditions if no medical necessity to justify home health using teach back method.
- Assess need and provide basic diabetic teaching (glucose meter testing, etc.)
- Assess need and obtain required order for patient to receive disease management teaching or counseling (MD referral required for billing)
- Document Care Coordinators interventions in Care Management Tracking database and patient record
- Refer non-nursing functions, such as assisting patients with completion of Medicaid, disability, pharmacy program or other eligibility applications, and scheduling appointments to designated resources in the region
- Coordinate with Care Coordinators in other settings as appropriate (e.g. Case Managers of payers, etc.)
- Instruct patients on how to fill out screening and assessment tools for chronic conditions (depression, Alzheimer’s, etc.)
- Score and document results
- Explain results from screening based on protocol and guidelines
4. Patient Education:
- Provide pre-printed educational materials as needed, or at provider or patient request
- Do needs assessment and develop patient education plan
- Answer basic clinical questions
- Provide group education for established patients
- Must understand professional boundaries and appropriately refer diagnostic questions to MD
5. Ensures complete and accurate information in the paper or Electronic Health Record.
6. Coordinate referrals to community resources (e.g. home health, Durable Medical Equipment, support groups)
- Forward written physician orders for treatment
- Assess patient for additional needs, develop nursing plan of care and contact physician for order-dependent items
- Negotiate payment for non-covered benefits based on assessment of medical needs and projection of outcomes of care
7. Maintains adequate level of supplies for
8. OSHA, CLIA and HIPAA compliance.
9. Assists with completion of patient requests in a timely manner.
10. Timely and accurate filing/distribution of all patient information.
11. Other duties and responsibilities as assigned are complete on a timely, thorough and accurate basis.
12. maintain a good working relationships and lines of communications with the hospital case management and utilization review staff for coordination of care and care transitions
13. Works with utilization personnel to monitor readmissions and utilization of hospital services.
14. Work with providers and office staff to identify appropriate patient population for advanced care management.
15. Work directly with patient to educate and manage their disease processes.
16. Manage, assign and perform home visits with patients as needed.
17. Will collect and report on routine data as directed by manager
18. Attend meetings as required.
19. Scope limitations:
May not provide therapy or counseling to suicidal patients (refer to 911 and notify provider)