Full-Time -Grant funded Position
Summary of Position:
The Be Healthy Partnership (ACO) located in Springfield, MA is looking for a Care Coordinator (Full Time, Day Shift) to work within their existing practice as part of a team-based care delivery model.
The Care Coordinator organizes, coordinates, and facilitates the provision of high quality, cost effective primary care services. In conjunction with the rest of the team, the Care Coordinator assures excellent internal and external customer service (patients and families, referral sources, employees, health system partners, etc.) in all settings.
The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff and community resources in a team approach to:
- Initiate and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)
- Increase continuity of care by managing relationships with care providers, transitions-in-care, and referrals
- Promote timely access to appropriate care
- Increase utilization of preventative care
- Increase patient and family comprehension through culturally and linguistically appropriate education
- Reduce emergency room utilization and hospital admissions
- Increase patients’ ability for self-management and shared decision-making
Essential Duties and Responsibilities:
- Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources
- Work with patients to plan and monitor care:
- Assess patient’s unmet health and social needs
- Initiate a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate)
- Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
- Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time
- Works seamlessly with primary care and behavioral health providers, ancillary staff including other nurses, medical assistants, pharmacy, IT, front desk, and any other staff to integrate patient care.
· Monitors delivery of care by completing patient rounds; documenting care; identifying progress toward desired care outcomes; intervening to overcome deviations in the expected plan of care; reviewing the care plan with patients in conjunction with the direct care providers; interacting with involved departments to negotiate and expedite scheduling and completion of tests, procedures, and consults; reporting personnel and performance issues to the unit manager; maintaining ongoing communication with internal staff and especially external agencies regarding variances from the care plan or transfer/discharge plan.
- Demonstrates knowledge of applicable laws and regulations, developmental stages, pharmacology, health promotion and disease prevention and treatment, best practice interventions, primary care policies and procedures through daily interactions with staff, physicians and patient/families.
- Acts as a positive influence on team members in promotion of team and Be Healthy Partnership goals through personal respect and professionalism. Inspires cooperation and excellent performance.
- Works closely with a Nurse Care Manager to assure comprehensive assessments are completed according to department standards, and that regular clinical education is addressing identified needs
Education and/or Work Experience Requirements:
- Associates Degree or equivalent experience
- Driver’s License required
- Demonstrated technical experience with Microsoft Word, Excel (or similar databases), and Internet Explorer
- Willingness to work some weekend/evening hours depending on project needs
- Excellent communication skills, approachable work style and a willingness to take on complex organizational and clinical activities
- Must be highly organized with the ability to work well with people
- Must have the ability to work with highly sensitive and confidential information
- Experience working with Senior Leadership across multiple settings
- Ability to speak a relevant second language is desirable
· Previous experience in care management of complex patients in the outpatient and/or inpatient setting OR evidence of the ability to fulfill the duties of this position.
Core Skills and Competencies:
· Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state and local standards, including meeting qualitative and/or quantitative productivity standards.
· Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards
· Must be able to talk, listen and speak clearly on telephone
About Be Healthy Partnership (ACO)
The Be Healthy Partnership is an alliance between Baystate, Baycare, Caring Health Center, and Health New England focusing on delivering high quality of care for the Medicaid population. The primary focus of this alliance is to improve the health and lives of our ACO members, as well as to control rising costs of care by implementing innovative delivery system changes that proactively meet the complex needs of our patients, including efforts to manage their behavioral and social needs in addition to their medical care.
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