Job Title

Job Type Full-timeDescriptionPURPOSE STATEMENT:Responsible for assisting in coordinating team-based care, to provide health services to individuals, through effective partnership with patients, their caregivers/families, community resources and members of the Care Team.ESSENTIAL FUNCTIONS • Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.• Work with RN's and payers to plan and monitor patient care.• Assess patient's unmet health and social needs. • Facilitate patient access to appropriate medical and specialty providers. • Educate patient and family/caregiver(s) about relevant community resources. • Facilitate and attend meetings between care team, payers, and community resources, as needed• Assist with the identification of "high-risk" patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR)• Follow up and monitor patients via payer work lists to assist in scheduling and following patient chronic care diagnosis. • Attend all Care Coordinator training courses/webinars and meetings• Display knowledge of preventative health requirements• Maintain regular and predictable attendance• Perform other essential duties as assignedRequirementsEDUCATION/EXPERIENCE/SKILL REQUIREMENTS• Current Certified Medical Assistant certification or licensed practical nurse• BLS • Previous experience in caring for chronic disease patients preferred• Two years' experience in clinical or community health setting preferred• Previous Care Coordination, Case Management or Home Health experience preferred• Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the hospital/clinic.