Care Coordinator

Duties/Responsibilities:

Partners with providers to identify patients appropriate for chronic care and case management programs and follows processes for enrolling patients.

Provides ongoing comprehensive care management of assigned patients. This includes assessing the holistic needs of the patients, facilitating timely preventative services, reviewing medications and patients' self-management of medications, and coordinating care with other home and community-based providers as needed. Assists in closing quality gaps and providing patient education.

Follows standing orders and protocols to meet quality initiatives and to improve patient outcomes.

Engages with patients by utilizing motivational interviewing to understand patient baselines, promote optimal health and encourage completion of necessary screening tests.

Assists in developing process and procedures that ensures thorough review of multiple patient level actionable reports, such as care reports, ER/Discharge patient lists, and risk adjustment lists.

Evaluates the effectiveness, necessity, and efficiency of the treatment plan and communicates with the PCP and health care delivery team to recommend changes.

Completes Transitional Care calls and documentation requirements for all identified patients to facilitate and oversee discharge planning needs.

Facilitates PCP and/or Specialist post discharge hospital follow up appointments and documents available facility treatment history.

Communicates clearly with all team partners.

Works effectively with available Care Coordinators to coordinate case transition when needed.

Identifies and builds effective relationships with a network of community resources.

Establishes and maintains a professional, collaborative positive relationship with the patient, family, physician(s), and other providers to assess the options for care and use of benefits and community resources.

Maintains appropriate documentation and tracking as required by BWC, insurance companies and Accountable Care Organization (ACO) partners.

Coordinates and identifies high risk population with a history of polypharmacy, to improve quality outcomes with appropriate support services in managing pharmacy needs.

Acts as liaison between BWC and other entities regarding prior authorization requests.

Educates team partners regarding BWC's health management programs.

Represents BWC as a member of a cross-functional project team. Education & Experience:

Current license as a CMA, LPN, or RN

Care Management experience is preferred.

Equal Opportunity Employer

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