Job Description

Job Overview:

The Care Coordinators are responsible for optimizing the health and well-being of our patients to enhance their quality of life and health using cost effective resources and services.

The Care Coordination team utilizes a systematic approach to provide care coordination, identify gaps in care (HEDIS measures), post hospitalization transitional care support, health promotion, and assistance with coordination of available health plan benefits to enable optimal well-being. Through various telephonic surveys, patients’ needs are ascertained so that the care coordinator can assist the patient with meeting those needs.

Key Responsibilities:

• Learn the patient's needs and priorities by completing the following Care Coordination Engagement types via telephonic outreach
• Outreach to new patients
• Completing health surveys to understand the medical, functional, cognitive, psychosocial and/or mental health needs of each patient
• Learn any barriers preventing the member from taking care of their health
• Understand the member's health goals and priorities
• Communicate findings with patients PCP
• Transition of Care (TOC) calls for hospitalized and post-discharge patients
• Outreach to educate and assist patients to schedule appointments preventive health services to help close HEDIS/Stars gaps in care
• Schedule appointments, arrange for transportation and contact PCP/Health Plan as needed to facilitate care access and closure of gaps in care
• Assist patient in finding community resources to address social needs, such as food insecurity and shelter
• Serve as the patient’s advocate if they become sick
• Facilitate access to care and benefits
• Coordinate care across the member's providers
• Provide transitional care support post discharge from a hospitalization visit

Please note that the responsibilities and duties outlined above are subject to change based on the evolving needs of the company.

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