The Care Coordinator will work with other medical professionals to provide the best healthcare possible to patients. This coordinated, team-based care will be provided to individuals through effective partnerships with patients, caregivers, families, community resources, and their physician with the Care Coordinator serving as the primary contact point, advocate, and resource.  The Care Coordinator will work in collaboration and continuous partnership with the patient to ensure that the patient understands every aspect of their care and will promote adherence to a care plan developed in coordination with the patient, primary care provider, and family / caregivers. The Care Coordinator will connect patient to relevant community resources with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reduction health costs by managing relationships with tertiary care providers, transitions-in-care, and referrals.  This individual will also work with administration to create policies and make decisions that are in the best interest of patients and will facilitate a shared goal model across settings of care to achieve coordinated high-quality care that is patient and family centered.

• Promote timely access to appropriate care
• Increase utilization of preventative care, reduce emergency room utilization and hospital readmissions
• Provide medication reconciliation
• Assess patient’s unmet health and social needs
• Develop a care plan with the patient, family/caregiver, and providers and monitor adherence to these care plans evaluating effectiveness, patient progress, and facilitating change as needed

• Facilitate patient access to appropriate medical and specialty providers
• Educate patient and family/caregivers about relevant community resources
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow up, and integration of information into the care plan regarding transitions-in-care and referrals
• Assist in the identification of high-risk patients
• Implement an effective internal tracking system for identified patients
• Promote health behaviors in all populations and ensure navigation assistance with community resources
• Ensure active tracking of test results, medication management, and adherence to follow-up appointments

Education

Must be a current licensed Practical or Registered Nurse or Medical Assistant

or have obtained a bachelor’s or master’s degree in Social Work

Minimum Work Experience

2 + years of experience in a clinic, hospital, or quality management environment

Required Skills, Knowledge, and Abilities

• Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers
• Experience in, and sensitivity to, the unique dynamics of an integrated hospital system
• Exposure to and participation with health IT systems and data reports
• Demonstrated skills in planning, organizing, decision making, analytical thinking, and communication required
• Demonstrated skills in Quality Improvement and operational improvements (e.g. “Lean”) methods.