The Care Coordinator will support the clinical team to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum. This includes coordinating care with external providers, tracking and processing of essential documents related to individual care, monitoring, updating and ensuring data accuracy of agency care management systems. Essential Duties and Responsibilities include the following. Other duties may be assigned. Serve as ambassador to agency care and data management systems and monitor daily to ensure timely data entry; accuracy of information and ensuring systems integrity. These systems are not limited to but include: HRST, All Docs, Monday & Client Provider Visit Calendar, Ring Central and Zoho mail. Login in credentials will be made available. Monitor, track, receive, schedule pickup and process all Office Visit Reports (OVR) and Discharge Summaries (DS). This activity would minimally include the following: Receiving of

OVR & DS

delivered to corporate office or designated area by staff. Monitor and track completion of daily appointments, notify all home leads daily of upcoming appointments and confirm transportation for clients. Provide same day and prior day tracking of OVRs due by contacting all home leads and or transporters and request the completed OVRs be faxed to corporate office. Provide verbal coaching to any staff member for OVR variance, policy or practice violation. Review and process each OVR and DS to ensure: (1) new/changed or discontinued medications and diagnosis are recorded timely in each data management system (2) follow-up dates/times provided are immediately recorded within the Client Provider Visit Calendar and verbally reported to the staff and individual; (3) follow-up time periods ie, "within 90 days" provided, requires Coordinator to contact the provider office and request to schedule the appointment; and that appointment date/time be immediately recorded within the Client Provider Visit Calendar and verbally reported to the staff and individual. Report OVR and DS salient findings and requirements to nurse supervisor and in management meetings as requested. This report would minimally include new and changed diagnosis, conditions, medications and treatments. Verify any electronic prescription or medications/supply orders sent to pharmacy by providers have been received and confirm delivery time. Ensure that all OVRs and DS once reviewed/processed are initialed/dated (by reviewer) in lower corner of the document and made available to the RN or nurse supervisor for final review and signing. Monitor and complete the Quality Monitoring & Training Tool for Clinical Metric Daily. Assess for barriers to care and completes outreach to individuals according to care related needs, clarification of information, condition status, or personal concerns observed or reported. Participate in monthly medication audit to support with the process; identify and document any identified concerns; rectify the identified concerns by contacting all relevant stakeholders; updating the HRST, All Docs, Monday & Client Provider Visit Calendar systems as needed. Performs ongoing monitoring of individuals Healthcare Plan/Plan of Care, to ensure accuracy and update as needed and to identify and suggest necessary changes. Ensure monthly, quarterly and annual provider visits are scheduled and completed to minimally include Primary Care, Psychiatry, Dental, Vision, Podiatry and any other required specialty visits is scheduled and attended by client. Participate in required meetings, training and outside agency meetings with individuals inter disciplinary team in addition to admission, discharges and client transitional processes. Preferred candidate will have care coordination experience, be bilingual, proficient with typing and in MS products.

•Care Coordinator II position requires a license as a nurse!

Pay:

$16.00 - $18.00 per hour Expected hours: 25.0 per week

Work Location:

In person