The Care Coordinator would manage the pediatric, adolescent, and also the Private insurance population. They would work with the schools, parents, primary care and any specialists involved in care. The Care coordinator would collaborate care to create a more cohesive, streamlined experience for the patient between healthcare providers.
Current Michigan Registered Nurse (RN) License or Licensed Practical Nurse (LPN) pursuing RN.
Previous experience in caring for chronic disease patients required.
3-5 years' experience in clinic or community health settings preferred.
Previous Care Coordination, Case Management or Home Health Experience preferred.
Demonstrated evidence of essential leadership, communication, education, collaboration, and counseling skills.
Proficiency in communication technologies.
Effective organizational skills and demonstrates ability to maintain accurate notes and records.
Previous experience with health IT systems and data reports preferred.
Business background knowledge of Excel, eClinical Works, and CPSI beneficial.
Previous experience with mobilizing community resources, navigating patients through the healthcare continuum, and working with disparate populations preferred.
Ability to identify and implement appropriate patient communication strategies and overcome accessibility barriers as required.
DUTIES AND RESPONSIBILITIES:
Implement an effective internal tracking system for identified patients.
Implement an effective tracking system for quality of care measurement performance.
Become the leader on care measurements for all patient payers and provide guidance to providers and staff on what information should be addressed and gathered and how to better guide patients to meet measurable outcomes of health care.
Coach patients/families toward successful self-management of their chronic disease.
Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care through assessment, communication, care plan development monitoring, and modification.
Promote health behaviors in all populations and ensure navigation assistance with community resources.
Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialist (e.g., Diabetic Education).
Cultivate and support primary care and specialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions in care and referral.
Serve as the contact-point, advocate, and information resource for patient, family, care team, payers, and community resources.
Develop systems to support workflow and prevent errors.
Facilitate and attend meetings among and between patients, families, care team, payers, and community resources as needed.
Attend and participate in training and meeting activities related to care coordination (e.g., Health Coach certification, quarterly Regional Workshops, cohort calls with other care coordinators in accountable care organizations - ACOs - including the National Rural ACO).
