Care Coordinator
This job profile is not included in a recognized pathway.
Description
This position is responsible for identifying, coordinating, and assisting patients with social determinates of health needs to improve patient health outcomes.
Tasks
- Identifies and manages patients affected by social determinates of health though the use of the AAFP Social Needs Screening Tool.
- Works with providers and patients to link and refer patients to community agencies and services in the communities.
- Provides patients with self-management tools to address social determines of health following approved care plans.
- Schedules transition of care appointments for patients transitioning from inpatient settings to home and community settings.
- Assists providers and patients with the completion of community applications and documentation requirements including Medicaid MAS 2015/2020 forms.
- Maintain patients Circle of Care within eClinicalworks and coordinates communications between the organization, patients, and community agencies including case management services.
- Markets patient centered care services to the greater communities and various community agencies.
- Keeps up to date lists of community resources available to patients for outreach and referral purposes.
- Establishes and maintains relationships with community agencies and works with surrounding agencies to improve patient care services and community health outcomes.
- Works with community agencies to provide community-based outreach and education programs to improve community health outcomes.
- Maintains appropriate and accurate documentation, messaging, and care plans in the EHR.
Qualifications / Education
- Associates degree in a business or healthcare related field is required
- Three (3) years of care coordination experience is required if no Associates degree
- Bachelor’s degree preferred
- One (1) to two (2) years of medical office, social work, or clinical practice experience preferred
- Must posses problem solving and time management skills
- Must possess compassions, empathy, and excellent customer service skills
- New York State Office of Health Marketplace navigator certification preferred
- Experience with Microsoft Office and eClinicalWorks (EMR) preferred
