Care Coordinator

Conference Center 703 S Ave B BLDG A Yuma, AZ 85364, USA

• Functions as a liaison for patient/caregiver/family in navigating the continuum of care and serves as a patient advocate in inter-disciplinary meetings.
• Collaborates with the patient-centered medical home inter-disciplinary team including providers, pharmacists, dentists, behavioral health providers, chronic disease specialists, community health workers, and nurse/nursing support personnel to achieve patient outcomes.
• Interacts with patients, caregivers, provider teams and the community to achieve continuity of care, coordination of services, timely follow-up, and care planning.
• Develops and maintains accurate care coordination records of each referred patient within the electronic health record.
• Collaborates with health plans, hospitals, and utilise internal reporting capabilities to identify patients who have a recent hospitalization or emergency department visit to assist with care transitions.
• Proactively identifies social determinants of health by collecting information and addresses barriers to care by referring the patients to the appropriate community resources. Maintain a current list of community agencies and resources to provide to patients, caregivers, and provider teams.
• Provides support services and/or appropriate referrals for patient, caregiver and family as recommended by the inter-disciplinary teams.
• Assures quality of care by adhering to evidence-based guidelines policies and procedures.
• Participates in value-based care through shared-savings programs and in managed care, such as ACO, by assisting in improving patient outcomes and decreasing healthcare costs.
• Participates in the Quality Program through incident reporting and identifying opportunities for improvement.
• Participates in the Compliance Program through fraud, waste, and abuse prevention, detection, and reporting; and protecting patient confidentiality under HIPAA.
• Participates in the Infection Control Program through following hand washing and Blood b orne Pathogen safety and exposure protocols.
• Other duties as assigned.

• Education:
  
  High School or better in HS Diploma.
• Licenses &
  
  Certifications:
  
  MA or CNA CERT.

• Required:
  
  Advanced
• Basic Computer
  
  Skills:
  
  Advanced
• Preferred: (none)

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.