Care Coordinator

Responsibilities

• Collaborate with providers and clinical care teams to identify patients who would benefit from care management and coordinated services, ensuring comprehensive, patient-centered care across the continuum of care.
• Assess patients' physical, behavioral, social, and healthcare needs; coordinate appropriate services; support preventive care initiatives; review medicate adherence; and facilitate connects with home health, specialists, and community-based resources.
• Support quality improvement initiatives by helping close care gaps, promoting preventive screenings, and providing patient education to improve health outcomes.
• Follow established clinical protocols, standing orders, and best practices to support quality metrics, regulatory requirements, and vale-based care objectives.
• Build trusting relationships with patients through motivational interviewing techniques, encouraging engagement in their care plans, healthy lifestyle choices, and completion of recommended screenings and follow-up care.
• Assist in developing and maintaining processes for reviewing and managing actionable patient reports, including care gap reports, hospital and emergency department utilization reports, discharge lists, and risk adjustment reports.
• Complete Transitional Care Management (TCM) outreach and documentation for eligible patients, supporting successful transitions from hospital or facility settings to outpatient care.
• Coordinate timely post-discharge follow-up appointments with primary care providers and specialists and ensure pertinent hospitalization and treatment information is documented and available to the care team.
• Work closely with providers to identify patients who may benefit from chronic care management, care coordination, or case management services and support patient enrollment and ongoing participation in these programs.
• Maintain clear, professional, and timely communication with providers, patients, caregivers, and interdisciplinary team members.
• Develop and maintain collaborative relationships with community organizations, healthcare partners, and support services to address patient needs and enhance access to care.
• Build and maintain strong, collaborative relationships with patients, families, providers, and community partners to assess care needs, identify appropriate treatment options, and connect patients with available benefits and support services.
• Maintain accurate and timely documentation, reporting, and tracking requirements in accordance with organizational guidelines, payer requirements, and Accountable Care Organization (ACO) partnerships.
• Identify and support high-risk patient populations by coordinating appropriate interventions, resources, and services to improve quality outcomes and patient well-being.
• Serve as a liaison between providers, patients, insurance carriers, and other healthcare entities to facilitate prior authorization requests and support access to medically necessary services.
• Promote awareness and understanding of health management and care coordination programs by providing education and resources to providers, staff, and other team members.
• Participate on cross-functional teams and organizational initiatives to support quality improvement, population health management, and strategic objectives.
• Maintain effective communication and collaboration with interdisciplinary team members to ensure continuity of care and positive patient experiences.
• Perform other duties and responsibilities as assigned by leadership and/or an authorized licensed provider.