Job Summary: Responsible for coordinating care for populations of patients in treatment or recovery primarily at PCC's Austin Recovery Connections program. Ensures referrals generated by PCC are completed by addressing barriers to care, increasing patient motivation, and establishing professional, dynamic relationships with patients, providers, referral sources, and other involved parties.
o Establish relationships to coordinate patient referrals between patient's provider and referral source to promote patient-centered services and ensure all reports are received by PCC
Collaborate with providers, patients, and clients to match needs with available resources
Advocate on patient's behalf if needed to ensure completion of referrals
Decrease barriers to care, increase motivation, and foster open communication
Contact referral sources when reports/results are outstanding, request results/reports not automatically received by PCC
Directs all reports to primary care provider.
Works with Recovery Care Managers and entire ARC & Recovery Care Coordination team to identify treatment options
Notifies primary care provider of any incomplete/unsuccessful referrals
Produce basic reports
Achieve outcome-based metrics for performance
Maximize services within care coordinator scope and refer to other staff as needed based on patients' need and staff members' position, licensure and scope of services
Regularly attend and participate in monthly site team meetings
Contribute to patient education materials and strategies to support care coordination
Work with manager and team to create flow charts, workflows and document tracking process as needed
Work with PI department to utilize computerized databases for tracking of identified high-risk areas by collecting, reviewing and inputting data into database and following up on failed follow-up visits per program guidelines
Follow guidelines to enhance care coordination for high-need, high-risk patients, tracking of high-risk areas as needed
Develop supportive services and tools to address common barriers to care for PCC patients; integrate these with other initiatives for health promotion/education and access to care
Performs other duties as required and assigned
Basic Qualifications
Experience/Training:
Physical Demands:
Other Skills: