Patient Health Coordinator

Responsibilities

• Aid in care coordination efforts and meet the needs of the patient panel.
• Collaborate with cross-functional teams to solve problems and achieve objectives.
• Act as the liaison between the provider and patient by coordinating in-market activities, such as relaying messages, processing referrals & faxes, and handling prior authorizations.
• Maintain and evaluate the effectiveness of interventions and treatments, adjusting the care plan as necessary.
• Contribute to essential care coordination efforts, including managing Transitions of Care, facilitating access to community services and resources, and addressing quality care gaps.
• Advocate for patients' well-being, ensuring they receive the care and support they need.
• Reach out to patients who are discharged from the hospital or emergency room to understand, collect information, and close care gaps.
• Identify, document, and resolve problems, goals, and interventions in care plans.
• Communicate clinical information and instructions to patients/caregivers, facilities, etc., on behalf of providers, as directed.
• Work as part of a collaborative care team to achieve optimal quality and patient experience outcomes, including being an active member in High-Risk Huddles.
• Identify and ensure closure of Social Determinant of Health barriers.
• Proactively monitor patients' care through outreach efforts and regularly established checkpoints based on care plans.
• Document all phone calls and patient interactions in the EHR promptly using standard clinical documentation guidelines as required by the company and local, state, and federal rules and regulations.
• Maintain clear and compassionate communication with patients, family members, care team, and other external entities, representing the company in a professional and courteous manner in all interactions.
• Appropriately identify, acknowledge, escalate, and/or address patient complaints, grievances, and concerns in a timely and effective manner.
• Adhere to all state and federal laws, including HIPAA.

Qualifications

• High school diploma/GED with 2+ years of care coordination or healthcare experience.
• Familiarity with Medicare, Medicare Advantage, and Medicaid insurances and programs.
• Well-organized, detail-oriented, and capable of multitasking in a demanding and constantly changing environment.
• Strong interpersonal communication skills and the ability to communicate easily with others, including demonstrating active listening skills.
• Demonstrated flexibility in addressing changing community needs and program environments.
• Strong time management skills.
• Strong commitment to patient advocacy.
• Self-directed with excellent problem-solving skills.
• Knowledge of basic medical terminology.
• Proficiency with EMR software/application, call center technology, and Microsoft Office Suite.
• Experience in a community work or healthcare environment.
• Knowledge of basic principles, practices, and techniques in primary healthcare.