Care Coordinator Field (MA)

Definition:The Care Coordinator is responsible for driving the intake process and communicating patient needs. The Care Coordinator strives for communication excellence by bridging the gaps between patients, caregivers and all members of the care team. The Care Coordinator will assist the Providers in their appointments and care coordination needs.This person builds a trusting relationship with patients and caregivers by understanding their critical needs and conveys that information to the care team. The Care Coordinator plays a vital role and is integral at every hand-off throughout the patient journey.The Care Coordinator reports directly to the Director of Nursing of Intrinsia Health.Responsibilities:Perform all Care Coordination needs (including):Conduct outreach to patients and their family members to coordinate and schedule visits with the ACO REACH providerDevelop rapport with patients, caregivers, and others in the home or facilityRequest patient H&P and clinical documentsConduct initial intake and review health history with patients and family in their homeEnter and update demographics, ensure practice forms are signed, and document timely working in patient’s chartMeasure patient vital signs, including height, weight, body temperature, blood pressure, pulse, and respirationsPerform pre-provider screenings based on patient history and needs by obtaining personal medical data, including health history, current medications, reason for visit, etc. and recording in the medical recordScreen patient unmet needs and review charts, labs, and self-management goals in pre-visit chart review and schedule needed services prior to visitAdminister routine medications under physician/NPP orders, which may include but are not limited to immunizations, antibiotics, vitamins, and topical agentsFollow up on all tasks, including open orders for e-prescribe, medication refills, DME, laboratory, specialist referrals and home health, follow up with patients across care transitions, and assist in entering medication and patient history into EHRCommunicate accurate and timely information with patientsAssist with accessing, scanning, and maintaining medical recordsNotify care team members when visits are not completeVerify that visit notes are completed within 48 hours of visitCreate and submit super bills, following established workflows to ensure accurate and timely billing completionCommunicate with providers and other members of the care team to ensure processes flow smoothly and make adjustments as necessaryNotify patient’s PCP and/or practice staff of change in patient status or need for follow upOption to travel, including out-of-state, to contracted Participant Provider locations to support ACO REACH patient visits, foster provider and staff engagement, and ensure effective coordination of care and program initiativeWhen appropriate, and in collaboration with Participant Providers, assist with Voluntary Alignment activities to support patient engagement and ACO REACH program requirementsAssist in educating patients and families on Medicare Approved Benefit Enhancements and contracted Preferred Providers when applicableAssist with community education regarding Intrinsia, the ACO REACH program, and available servicesQualifications / Skills:Graduate of a Medical Assistant certificate or Certified Nursing Assistant program requiredPalliative Care / Home Health experience preferredExpert customer service abilityPossesses an ability to maintain good interpersonal relationships with patients, families, co-workers, and other health team membersLearns and understands the roles of all members of the care team #J-18808-Ljbffr Intrinsia Health Llc