Care Coordinator

Description

Summary/
Objective

The Care Coordinator is a core member of the care team, including the patient’s medical provider and psychiatric consultant, and the larger primary care team. The Care Coordinator is responsible for supporting and coordinating the overall health of patients, with a focus on chronic conditions, preventative care, and healthy behaviors.

Essential Functions

Communicates to patients the purpose of the program and the impact it may have on their wellbeing.
Helps patients identify social determinates of health that affect their overall health and develop health and social management plans and goals.
Educates the patient on the proper use of the emergency room and provides information for alternatives.
Assists patients in understanding care plans and instructions. Motivates patients to be active and engaged participants in their health and overall wellbeing.
Responsible for developing a comprehensive individualized plan of care and targeted interventions incorporating the patient’s preferences and SMART goals.
Effectively communicates with the patient’s care team / PCP to exchange information about the patient and give updates on progress made with self-management support services.
Ensures age applicable health assessments/screenings are completed timely and documented in the electronic health record appropriately.
Continual development of knowledge and understanding of community resources, NorthShore services, and programs offered.
Completing transitions of care for ER/IP visits for patients within 72 hours of discharge and documenting findings appropriately in the patient's electronic health record.
Closing the loop on all external referrals and obtaining outside records and results.
Addressing gaps in care and documenting results in the patient’s electronic health record.
Assists with patient/provider requests for durable medical equipment, home health services, FMLA requests, etc.
Completes glucose testing, Continual Glucose Monitoring Device (CGM) placements, basic vitals, and other tests assigned by management.
Provides follow up to patients to find out if they are meeting goals and how they are managing health issues, celebrates successes, and provides suggestions to overcome barriers to care.
Maintains top quality proficiencies across all training areas in daily work.
Attends meetings and training sessions as required.
Executes other assigned tasks as requested by management.

*These essential functions are a summary of the primary duties and responsibilities of the position and are not intended to be a comprehensive listing of all duties and responsibilities. The position will include other duties as assigned and duties are subject to change at the management's discretion.

Competencies

Planning and strategic foresight
Responsible Decision Making and Problem Solving
Integrity and accountability
Innovation and creativity
Adaptive and flexible
Leadership, teamwork, and conflict resolution
Professionalism and work ethic
Empathy

Work Environment

Work is performed in an ambulatory care environment. Involves frequent personal and telephone contact with patients, physicians, and other healthcare personnel. Work may be stressful at times. Interaction with others is constant and interruptive.

Travel

Travel outside of Northshore locations will be rare for this position.

Qualifications

Required Role Qualifications

Minimum required education per state of Indiana/HRSA
1 year of care coordination experience
Community Health Worker Certification within 1 year of hire
Valid CPR certification

Preferred Role Qualifications

Two years of experience working within a healthcare setting.
Certified/Registered Medical Assistant, Licensed Practical Nurse, Advanced Practical Nurse or Registered Nurse licensing
Bilingual preferred

Required Skills

Ability to analyze situations and solve problems at strategic and tactical levels
Excellent interpersonal and customer service skills
Ability to comprehend, interpret, and apply the appropriate sections of applicable laws, guidelines, regulations, ordinances, and policies
Ability to acquire a thorough understanding of the organization's hierarchy, jobs, qualifications, compensation practices, and the administrative practices related to those factors
Practiced at organization and planning
Employ Critical thinking and problem solving
Maintains composure and operates with emotional intelligence
Ethical reasoning and decision-making
Strong attention to detail
Receptive and responsive to feedback
Excellent verbal and written communication skills
Time management, prioritization, and sense of urgency
Proficient with Microsoft Office Suite or related software

Physical, Visual, and Audible Requirements

Physical Requirements

Activity

Occasionally (1 -33%)

Frequently (34-66%)

Continuously (67-100%)

Sitting

X