The Care Coordinator/Managed Medicare actively care manages an assigned panel of Managed Medicare patients in the Primary Care Practice, encompassing aspects of care including specialist referrals, hospitalizations and ancillary testing.
- Provides members enrollment into qualifying programs such as, but not limited to: Medication Vouchers Programs, Diabetes supplies, Diabetic shoes.
- Ensures all new initiatives, policies and procedures, guidelines or other necessary updates are incorporated into patient education programs to provide reconciliation and or verification of status, conditions and or medications.
- Manages patient caseload in an efficient and effective manner utilizing time management skills to facilitate the total work process managing assigned caseloads.
- Demonstrates expert practice skills that include flexibility, priority setting, problem-solving, conflicts resolution, negotiating and networking skills, decision-making, work delegation and organization, and verbal/written communication skills.
- Enters timely and accurate data into designated care management applications as needed to communicate patient needs.
- Develops a relationship with the patient as an integral member of the team.
- Documents all patient interactions in Allscripts.
- Assesses barriers to treatment goals including but not limited to: access, compliance and financial issues.
- Monitors hospitalizations, SNF and outpatient referrals to specialists and act as liaison for the PCP.
- Communicates with patients between visits via telephone or email (as appropriate) to monitor follow up compliance and health status.
- Identifications of all needed preventative health maintenance, immunizations and chronic disease interventions.
- Identifies patients not meeting clinical goals, such as BP or glucose control.
- When standing orders allow it, orders or completes the interventions before the patient sees a provider.
- Fills out pre-visit forms or initiates office visit forms to communicate the review to the provider.
- Anticipates patient needs.
- Identifies the high acuity patient and work more directly to ensure care management/coordination for this population.
- Acts as a liaison:
- With patients and their families to physicians, clinical staff and other departments.
- With hospitalized patients and the Primary Care practice; follows up with patients by phone shortly after hospital discharge.
- With specialty offices.
- With outpatient case manager.
- Proactively acts as patients advocates, responding to and working to resolve patient concerns.
- Works with PCP to develop individual care plans including follow up appointments, labs, care coordination and tracking towards treatment goals.
- Utilizes chronic disease management, wellness promotion, disease prevention programs.
- Collaborates with insurance/MSO case managers as appropriate to determine best Practices.
- Utilizes a list of medical supply and community resources available to patients and maintains collegial relationships with the most frequently used entities.
- Ability to ambulate.
- Ability to communicate by phone using standard telephone equipment.
- Ability to communicate verbally and in writing.
- Ability to lift up to 50 lbs. and assist with patient transfer from wheelchair to table.
- Ability to visually assess patients and equipment.
Education & Experience Requirements
- Successful graduation from an accredited nursing program.
- Valid Florida nursing license.
- 5 – 7 years geriatric experience.
Required tasks routinely involve a potential for mucous membranes or skin contact with blood, body fluids, tissues or potential spills or splashes. Use of appropriate measures is required for every health care provider in this position.
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