Care Management Coordinator

Care Management Coordinator

Requirements

• High school diploma or GED, required; Associates degree considered a plus
• Certified Medical Assistant (CMA) or Certified Nursing Assistant (CNA) or Health Coach Certification required
• Licensed Practical Nurse (LPN) certification preferred
• Prior work experience in a healthcare service environment required
• Prior experience with electronic health records or health registries required
• Able to learn new technologies and related processes and workflows, as well as contribute to process improvements when needed
• Strong Interpersonal communication skills with exceptional empathetic listening abilities
• Able to adapt with positivity
• Highly organized, able to prioritize work and multi-task
• Excellent telephonic, written, and verbal communication skills required
• Microsoft Office skills, including Excel, Word, PowerPoint, Outlook required, PowerPoint preferred

Responsibilities

• Build relationships with patients and/or caregivers telephonically and with internal and external care team members, including physicians, nurse practitioners, registered nurse care managers, social workers, pharmacists, transition of care coordinators, and other members of the IDT.
• Assist with the coordination of the patient’s care across the continuum, including activities such as requesting records and scheduling appointments with specialists, coordinating referrals, connecting with community resources, sharing or transferring information with the patient’s internal and external care team, retrieving records from the health information exchange, etc.
• Regularly monitor your assigned patients’ progress, track care plan milestones, and partner with IDT members to adjust care strategies as needed to ensure desired health outcomes.
• Provide ongoing patient follow-ups and reassessments using care best practices and Honest guidelines to ensure continuity of care.
• Communicate with patients by phone, monitor adherence to patient specific goals and care plans or in-person and escalate to the IDT when necessary.
• Complete assessments with patients or caregivers (post-discharge, PHQ2/9, SDOH screenings, etc.)
• When needed, schedule Honest providers’ home visits according to current practice. Complete reminder calls for scheduled home visits.
• Coordinate or create referrals for services or durable medical equipment, as directed by a registered nurse care manager or provider.
• Ensure annual wellness visits (AWVs) are scheduled within acceptable timeframes.
• Actively participate in Honest Health huddles and IDT meetings.
• Document and maintain accurate patient records and meeting minutes, as requested.
• Perform other related duties as assigned.

Preferred Qualifications

• Prior experience working as part of an interdisciplinary care team preferred
• Prior experience communicating with and educating patients about their health goals and available resources