Care Coordinator, RN

About this role

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Job Description: • Job Description

Position Summary:   Responsible for providing a variety of Care Coordination services within the Primary Care (PC) practice setting, for members that are considered at risk and/or who experience barriers to healthcare. Principle Care Coordination services include, but are not limited to, performing comprehensive assessments, focusing on member-centered care planning, providing episodic and  longitudinal care planning, monitoring acute facility stays and discharges, facilitating disease education groups, individual disease education, empowering member’s self-management skills and  understanding of their medical condition, and referring members to appropriate community resources.  

Care Coordinator, RN COMPETENCIES/Role-Specific Functions:  COMMUNICATION Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills. • Communicate assessment findings, care plan goals, interventions and outcomes to PC providers in a timely manner.

• Develop, communicate and implement care plans in coordination with members, caregivers, providers and care teams.

• Participate in Care Rounds, or similar type meeting, at the practice to furnish member reports and updates to care team and collaborate on care plans and strategies.

• Actively engage PC providers and staff in identifying high risk members and collaborate with providers and care teams on methods for navigating members’ care successfully along the care continuum.

• Communicate with all internal Physician Health Partners (PHP) departments effectively to result in optimal meeting of business needs.

• Communicates and collaborates appropriately to seek guidance and direction with management when necessary. 

PROBLEM SOLVING Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts. • Complete comprehensive assessments to identify needs and barriers to member’s ability to manage their medical conditions and treatment plans. 

• Pursue appropriate medical and/or staff intervention in a timely manner to assure problem resolution. 

• Provide crisis intervention services.

• Collaborate with peers, management and other appropriate resources on complicated situations.

• Displays Strength-Based Approach to collaborative problem solving.

PRODUCTIVITY Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, handles information flow. • Document member information, contacts and interventions in applicable care management software systems utilizing PHP Care Coordination Standard Operating Procedures.

• Actively identifies opportunities to enhancement, lean processes and overall improved delivery of Care Coordination services.  

• Strategically approaches the practice(s) with the goal of achieving optimal practice engagement, effective care coordination and collaboration to maximize positive member outcomes.

• Contribute to the Care Coordination team through staff meeting attendance and participation, lending assistance to co-workers, participation on committees, LEAN events and other PHP similar activities.

SELF DEVELOPMENT Seeks out and accepts feedback, is a proactive learner, takes on tough assignments to improve skills, keeps knowledge and skills up-to-date, turns mistakes into learning opportunities. • Has ability to receive feedback and apply it to work performance.

• Encourages others on the team surrounding their own self development.

• Demonstrates an understanding of current healthcare trends.

• Fulfills requirements necessary to maintain licensure.

• Identify opportunities for, and participate in, continuing education including workshops, conferences, specific publications, etc.

CUSTOMER FOCUS Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers. • Develop and maintain effective professional working relationships with assigned PC Practice(s) setting of providers, the members, care-givers, families and community resources.

• Identify and support practice needs for structured on-site Care Coordination presence in alignment with program models.

• Participate in practice meetings such as Quality and Provider Relations, as instructed by PHP Manager.

• Develop and maintain professional and effective working relationships with all PHP internal customers.

• Within the PC practice setting, develop and implement documented strategies for improving care coordination integration.

JOB KNOWLEDGE Understands duties and responsibilities, has necessary job knowledge, has necessary technical skills, understands company mission/values, keeps job knowledge current, is in command of critical issues. • Identify members that would potentially benefit from Care Coordination services, by using a variety of data sources, including but not limited to, high risk and utilization reports, prior authorization services, physician/practice referrals, referrals from other sources and practice EMR stratification data. 

• Complete visits with members, their caregivers and significant others in potentially a variety of settings, determined by program models and initiatives. 

• Provide evidence based crisis intervention services. 

• Employ motivational interviewing skills to elicit optimal member engagement/outcome.

• Complete required HIPAA training and maintain confidentiality through compli

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