Care Coordinator- Part-Time

Position Summary The Care Coordinator ensures patient navigation is implemented by managing client caseloads, coordinating primary and specialty care, overseeing transitions of care, and collaborating closely with patient schedulers for timely follow‐up appointments. Care Coordinators facilitate conversations between interdisciplinary care team members regarding transitions of care as well as patient family members post provider visits. This is a hybrid position reporting to either our Chapel Hill or Concord offices. Essential Duties And Responsibilities Client Caseload Management Assist with delivering quality care for patients with chronic conditions by providing critical insights and valuable data to eventus care teams Calling patient family members/POAs/caregivers to provide updates after provider visits, answer clinical questions Provide day‐to‐day support and supervision of care – ensuring labs, specialty notes, hospital and SNF records are available in EHR for provider review Review patients' medical history and information from all available information sources including internal care team and outside providers and services Perform medication reconciliation after a transition of care and summarize SNF/hospital stay Create Chronic Care Management (CCM) and Behavioral Health Integration (BHI) care plans with billing/rendering providers, including medications, diagnoses, patient goals, interventions, care team members, barriers, and patient education; update plans as necessary Ensure that the recommendations of the care plans are followed and proper treatment and therapies are provided Refer patients to needed services, such as specialist referrals Call patients/POAs/caregivers within 48 hours after a discharge from a hospital or SNF to check in and schedule a follow‐up visit Organizational and administrative duties Facilitate discussions with health care providers about client care plans, transitions of care, medication reconciliation, family input and specialty referrals Document client services in the patient chart, including updated history, medication reconciliation from transitions of care, and summaries of phone calls Track client information and appointments confidentially Initiate outreach and missed appointment procedures as necessary Assist in disseminating tasks needed by providers to achieve quality metrics for value‐based care programs (e.g., depression screenings, BP readings, and HbA1c results) Assist with coordinating physician visits with scheduling for LTC ACO and follow‐up appointments within 1 week for ACO‐eligible patients after a transition of care Track time spent in care coordination activities to document for chronic care management minutes Ensure that all Medicare requirements of the CCM and BHI programs are met Other duties as assigned Education and/or Certifications LPN degree or experienced certified MA with 5 years primary care experience Minimum of 2 years experience in the LTC/ALF setting Care coordination experience preferred Value‐based care experience ideal Strong understanding of cultural competency with the target population Competency with Excel, PCC, Matrix and Microsoft products, and ability to become proficient with company‐specific programs and software Interest in working with geriatric clients Skills and Qualifications Commitment to the mission of care coordination Excellent communication and interpersonal skills with the ability to speak concisely to clients, schedulers, families and interdisciplinary team members Strong knowledge of the geriatric population and patient navigation Organized with confidential client material, appointment tracking, and caseloads Desire to build relationships with patients, family members and other health‐care team members Strong organizational and time‐management skills, with the ability to prioritize tasks and meet deadlines Professional verbal and written communication skills via phone, email, and other correspondence Friendly and professional demeanor Physical Requirements While performing the duties of this job, the employee is regularly required to communicate with others, including the ability to express oneself and exchange information in sometimes high‐pressure environments. The employee frequently must move about the office to access files, use office equipment, and interact with others, and must be able to remain seated or in a stationary position for extended periods while working, communicating on the phone, and using the computer. About Eventus WholeHealth Eventus WholeHealth was founded in 2014 to provide physician‐led health‐care services for residents and patients of skilled nursing and assisted living facilities. With our highly‐trained team of physicians, psychiatrists, nurse practitioners, physician assistants, psychotherapists, podiatrists, optometrists, audiologists, and support staff, our comprehensive, evidence‐based model provides collaborative interdisciplinary care and seamless integration of a wide range of specialties. Our differentiated approach empowers facilities to reach their own goals and objectives and ensures better patient outcomes. For more information, please visit www.eventuswholehealth.com. #J-18808-Ljbffr