Care Coordinator, RN

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Job Description:

Position Summary:  Responsible for providing a variety of Care Coordination activities to support members in navigating physical and behavioral healthcare systems, understanding their benefits and reducing barriers to accessing healthcare services. Care Coordination activities include, but are not limited to, performing comprehensive assessments, creating member-centered care plans, providing episodic and extended programming, monitoring acute facility admissions and discharges, providing condition management education, empowering member’s self-management skills, and referring members to appropriate community resources.  

COMPETENCIES/Role-Specific Functions:

COMMUNICATION

Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.

• Communicate clearly and consistently with members related to their healthcare needs, benefits and goals.
• Communicate assessment findings, care plan goals, interventions and outcomes to member and care team in a timely manner.
• Participate in Care Rounds, or similar type meetings, to collaborate with healthcare team to address member needs, care plans and coordination activities.
• Actively engage healthcare providers and staff in identifying high risk members and collaborate with providers and care teams on methods for navigating members’ care successfully along the care continuum.
• Communicate with all internal Physician Health Partners (PHP) departments effectively to result in optimal meeting of business needs.
• Communicates and collaborates appropriately to seek guidance and direction with management when necessary. 

PROBLEM SOLVING

Breaks down problems into smaller components, understands underlying issues, can simplify and process complex issues, understands the difference between critical details and unimportant facts.

• Complete comprehensive assessments to identify needs and barriers to member’s ability to manage their medical conditions and treatment goals. 
• Pursue appropriate medical and/or staff interventions in a timely manner to assure problem resolution. 
• Provide information and resources to members for crisis management.
• Collaborate with peers, management and other appropriate resources on complicated situations.
• Displays Strength-Based approach to collaborative problem solving.

PRODUCTIVITY

Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, handles information flow.

• Document member information, contacts and interventions in applicable care management software systems utilizing PHP Care Coordination Standard Operating Procedures.
• Actively identifies opportunities to enhance programs and lean processes to improve delivery of Care Coordination services.  
• Strategically working with community partners and providers to maximize member outcomes through provider engagement, effective care coordination and collaboration.
• Contribute to the Care Coordination team through staff meeting attendance and participation, lending assistance to co-workers, participation on committees, LEAN events and other relevant PHP activities.

CUSTOMER FOCUS

Builds customer confidence, is committed to increasing customer satisfaction, sets achievable customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met, solicits opinions and ideas from customers, responds to customers.

• Identifies members, providers, healthcare system partners, state colleagues, and community-based organizations as customers.
• Seek to understand and address processes or barriers that impact a members ability to utilize benefits and/or access services.
• Complete visits with members, their caregivers and significant others in a variety of settings, determined by program models and initiatives.
• Develop and maintain effective professional working relationships with providers, members, caregivers, families and community resources.
• Seek to provide an excellent care coordination experience that is supportive to members mental, physical, social and cultural needs.
• Develop and maintain professional and effective working relationships with all PHP internal customers.

JOB KNOWLEDGE

Understands duties and responsibilities, has necessary job knowledge, has necessary