Job purpose The Care Coordinator is a vital member of the interdisciplinary patient care team. This role provides patient navigation and facilitates access to care based on gaps-in-care reports and Admissions, Discharges, Transfers reports. The Care Coordinator also identifies social determinants that are driving health and links families to community resources to mitigate social needs. Duties and responsibilities Reporting to the Director of Care Coordination and Integrated Support Programs, the Care Coordinator’s role will involve in-person visits with patients and families as well as telephonic visits. Patients who have been identified, as vulnerable, facing inordinate social risk, high utilizers of acute care or hospital services, or otherwise high-needs/high-cost patients, will comprise the panel of patients the Care Coordinator will address through measurable efforts to improve health and adherence/access to health care. Primary responsibilities include but are not limited to:
- Outreach to patient populations based on gaps-in-care reports or other reports that have identified vulnerable patients and families
- Manage the Connecticut Breast and Cervical Cancer Early Detection Program; a comprehensive screening program available throughout Connecticut for medically underserved women; the primary objective of the program is to significantly increase the number of women who receive breast and cervical cancer screening, diagnostic and treatment referral services
- Screen for social determinants of health at least yearly using a validated screening instrument on all patients with whom the Care Coordinator interacts
- Develop and evaluate shared plans of care
- Link patients with social needs to community resources
- Assist with and follow-up on the successful completion of health maintenance items (e.g. lab testing, annual visits) and chronic disease management (e.g. routine diabetic or asthmatic care)
- Conduct home visits as needed
- Identify barriers to care impacting patients’ abilities to adhere to treatments
- Work collaboratively with clinical teams to meet the clinical and social needs of high-needs, high-cost patients
- Attend relevant trainings as required and assigned
- Document client referrals, encounters, and services in the EPIC electronic health record and communicate securely with other team members and clinicians
- Maintain strict adherence to all deadlines including report deadlines and timely completeness of documentation
- Associates Degree in a health related field and/or relevant years of experience is required. Bachelor’s degree preferred, and a valid CT driver’s license and/or access to reliable transportation is required.
- Experience in Care Coordination; working with teams; using EPIC electronic health record highly preferred.
- The successful candidate will have excellent computer skills including word processing and data entry required and the ability to work independently. Bilingual in English and Spanish is highly desirable.
How to Apply
Please apply on our website using the link below:
Fair Haven Community Health Care