We are looking for a Care Coordinator that will be responsible for delivering transitional care and chronic care management services. Our team achieves results by being innovative, driven, collaborative and trustworthy.

While we've historically kept our team small, we simply can't ignore the opportunity ahead of us now. This is one of the most important roles we'll ever hire and will be responsible for executing against ambitious goals with significant autonomy and support.

Benefits:

• Great health insurance including: Medical, Vision, and Dental | Short Term Disability, Life Insurance, Critical Illness
• Generous PTO package and time-off on selected holidays
• Highly competitive salary and generous bonus
• 401(k) plan with an annual contribution of 2-3%

Role:

The Care Coordinator will be responsible for delivery of Transitional Care and Chronic Care Management services allowing patients to thrive and progress toward desired outcomes. Responsibilities include post-discharge patient outreach, patient-centered care plans, and service coordination utilizing software tools that facilitate communication and exchange of information with patients, CRC providers, and other care team members.

Responsibilities

• Detailed review of EMR record to inform initial outreach and care plan areas of focus
• Perform comprehensive assessments for both physical and psychosocial risk factors that support individual patient needs while identifying and addressing barriers
• Communicate assessment findings, care plan goals, interventions and outcomes to provider, patients, and caregivers in a timely manner
• Monitor patient’s ED visits and acute stays, perform post-discharge follow up calls and continuously assess risk of readmissions post-discharge
• Utilize motivational interviewing to promote patient engagement and empower patient to develop self-management skills
• Provide chronic disease education and symptom management teaching to patients and caregivers
• Communicate proactively with provider to address patient change in status or obtain any necessary referrals/orders
• Document care plans, clinical interventions, and outreach in care management software system
• Develop and maintain effective professional working relationships with assigned providers and other care management team members

Education and Experience:

• High school diploma or equivalent required. Associates or Bachelors preferred
• Licensed LPN/LVN or Registered Nurse
• A minimum of two (2) years of care coordination experience including post-discharge transitions of care required
• Experience providing care coordination to a skilled nursing and/or Medicare beneficiary population required
• Experience with SNF to home transitions of care or SNF bundled payment care coordination highly preferred

Competencies, Knowledge and Skills:

• Knowledge and experience with electronic medical record (EMR) and Care Management technology
• Display a strong customer service, patient-focused orientation
• Ability to be flexible in an ambiguous and dynamic environment
• Strong collaboration and conflict resolution skill sets
• Strong decision making and problem-solving skills
• Effectively engages diverse populations and provide culturally sensitive coaching, education, and assistance
• Ability to develop, prioritize and accomplish goals/time management

Job Type: Full-time

Pay: $28.00 - $32.00 per hour

Expected hours: 40 per week

Schedule:

• Monday to Friday

Work Location: Remote

Remote Clinical Care Coordinator id-12451