Care Coordinator

Care Coordinator Reports to: Care Manager

Status: Full-time (Hourly/Non-Exempt)

Summary of Position: The Care Coordinator supports patients by coordinating care services and helping them follow their care plans. The role includes regular patient outreach, identifying and addressing gaps in care, coordinating services with providers and community resources, and documenting activities in the CareVitality platform and/or Electronic Health Record of the client.

The Care Coordinator works closely with providers, care managers, and internal teams to ensure continuity of care and support positive patient outcomes.

Responsibilities:

• Conduct monthly follow-up with patients by reviewing the patient-centered care plan based on physical, mental, cognitive, psychosocial, functional, and environmental assessments, as well as an inventory of available resources.
• Provide Chronic Care Management (CCM) patients with appropriate educational materials and resources to support health education, self-management, and lifestyle improvement.
• Identify patients with gaps in preventive health services and assist with scheduling required screenings or diagnostic tests with their providers.
• Review and update patients’ current allergy and medication profiles, assess adherence and potential interactions, and communicate concerns to the patient and providers as appropriate. Support patient self-management of medications within the Care Coordinator scope.
• Engage patients through monthly care plan reviews that promote healthy lifestyles, close gaps in care, and reduce unnecessary emergency department utilization and hospital readmissions. Coordinate care with patients, caregivers, primary care providers, specialists, community resources, behavioral health partners, and other health plan or system departments as appropriate.
• Document all care coordination activities in the or CareVitality platform and possibly the Electronic Health Record if requested by the client in accordance with CareVitality standards, including required time elements, and identify trends or opportunities for improvement based on patient, provider, and system interactions.
• Health Risk Assessments (HRA), Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Advanced Primary Care Management (APCM) may be incorporated into the role as program needs evolve.
• Escalate patients requiring reassessment, care plan revision, or higher level clinical intervention to the assigned Care Manager in a timely manner.
• Transitional Care Management Services may need to be provided in any given month as part of the scope of services
• Provide transportation assistance if needed
• Gathering patients consent for various care management and remote monitoring programs.
• Perform other duties as assigned.