Care Coordinator II

Care Coordinator II The Care Coordinator II (CCII) plays a crucial role in onboarding and supporting the patient, including managing and coordinating their care plan. The CCII acts as a liaison between the patient or caregiver, primary care team, and external partners to ensure seamless communication and timely access to care. Primary responsibilities include working in tandem with the primary care team to coordinate healthcare services. The CCII assures continuity of care is maintained and optimized for the patient and their care team's well-being. Estimated Hiring Range: $28.81 - $35.22 Bonus Target: Essential Responsibilities Patient Communication Actively support an assigned panel of patients by providing timely complex care coordination for patients with physical and behavioral health care needs. Educate patients/caregivers on the services provided by Housecall Providers Primary Care. Escalate concerns to primary care team according to protocols. De-escalate high stress situations and complaints received and forwards to primary care team/leadership as appropriate. Coordinate referrals for supportive services, labs, diagnostics or other coordination of care needs as requested by the primary care team based on insurance, location, patient preference, and order type. Schedule patient visits for assigned panel of patients based on urgency, geographic location, appointment type, provider availability and frequency of visit standards. Clinical Support Authorize prescription refills for non-controlled drugs if approved by clinician. Provide pharmacy support including verbal orders, when appropriate, to expedite or clarify medication fulfillment. Provide primary care coordination support to assigned panel of patients with physical and behavioral health care coordination needs. Review, process and approve incoming referrals; ensure all intake documentation is complete and clinically relevant. Assess service appropriateness using medical terminology and clinical guidelines; collaborate with clinicians/supervisors for complex cases or exceptions. Responsible for meeting with DME vendors to maintain relationships and problem solve. Manage DME orders, ensuring charting and all documentation requirements are met. Support providers and patients with DME appeal process and follow up to make sure DME is delivered. Coordinate complex care with support services and community partners, including but not limited to home health, hospices, according to the patients' plan of care. Effectively coordinate care for patients with chronic and serious illness with internal and external stakeholders. Coordinate with the care team to ensure consideration is given to unique needs in integrated planning and that physical and behavioral health care plans are timely and effective. Develop working partnerships with patient, family, caregiver and community care providers, payors regarding patient needs and care plans. Assist with transitions in care from multiple settings to ensure continuity of care and address urgent issues appropriately. Work with care team to ensure transition in care visits are scheduled according to protocols. Update hospice and home health regarding patient hospitalizations and transitional care visits. Act as a consult to other teams and roles (external and internal) for geographically specific resources. Assist patients, caregivers and families in establishing/engaging with providers by coordinating appointment and transportation, as needed. Arrange family and/or caregiver attendance at appointments, and interpreters as required. Provide information about appointments, care plans, medications, referrals, prior authorizations, DME requests. Identify risk factors and service needs that may impact patient outcomes and address appropriately. Utilize a trauma-informed approach to provide patient-centric physical and behavioral health care and support including a person-centered approach to communication, education, and care planning. Assist patients with moving through the continuum of care based on clinical/medical/behavioral health needs by collaborating with the PCP, Primary Care Clinical Team (PCT), palliative care and hospice teams. Use motivational interviewing to coach patients toward improved physical and behavioral health care behaviors and self-management. Coordinate clinicians' diagnostic and lab orders, including lab and diagnostic testing, medical supplies and equipment. Provide timely outreach providing education, follow up on labs or diagnostics or clinical instructions from a member of the primary care team. Implement physical and behavioral health care coordination plan in collaboration with the patient's care team, including patient, family, caregiver, internal team mem #J-18808-Ljbffr