Care Coordinator

ESSENTIAL DUTIES & RESPONSIBILITIES

• Providers excellent customer service to internal and external customers
• Supports patient-driven requests via phone call, portal message, or provider/care team request via electronic health record (EHR), engaging patients as active participants in their care
• Assists patients in scheduling and completing referrals as needed by coordinating between the patient, provider(s), and the referral source
• 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
• Outreach patients after emergency room visits and/or inpatient admissions to ensure timely follow-up with primary care; obtain discharge records as needed
• Assists with training and supporting staff to follow department workflows within specialty area (Health Risk Assessments [HRAs], Care Manager delegated patient cases, patient support of HEDIs/Quality measures, proper documentation within Athena & MHNConnect2.com, etc.)
• Manage electronic health record team inboxes to ensure appropriate documents are send to primary care provider, team nurse, and other members of the care team.
• 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 outreach patients due for care, provide patient education, and facilitate appointments as necessary
• 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