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This job was posted by https://idahoworks.gov : For more information, please see: https://idahoworks.gov/jobs/2241781

Provides coordinated care to patients with chronic care conditions and or behavioral health needs by developing, monitoring, and evaluating interdisciplinary care. The Patient Care Coordinator coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a shared goal model within and across settings to achieve coordinated high-quality care that is patient- and family-centered.\

Essential Duties

1. Assess needs and provides a coordinated, strategic approach to detect early and effectively manage the patient population.\
2. Implement an effective internal tracking system for identified patients.\
3. Aid in determining gap assessment needs.\
4. Coach patients/families toward successful self-management of their chronic disease.\
5. Utilize tools and documents that support a guided care process, collaborate with patient/family toward an effective plan of care.\
6. Aid in Annual Wellness Visit coordination.\
7. Assess patient and familys unmet health and social needs.\
8. Provide effective communications to improve health literacy. Identify and implement appropriate patient communication strategies and overcome accessibility barriers, as required.\
9. Develop a care plan based on mutual goals with the patient, family, and providers emergency plan, medical summary, and ongoing action plan, as appropriate. Monitor patient adherence to plan of care and progress toward goals in a timely fashion, and facilitate changes as needed.\
10. Create ongoing processes for patients/families to determine and request the level of care coordination support they desire over time.\
11. Promote healthy behaviors in all populations and ensure navigation assistance with community resources.\
12. Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support specialists.\
13. Cultivate and support primary care and subspecialty co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.\
14. Serve as the contact-point, advocate, and informational resource for patient, family, care team, payers, and community resources. Respectfully resolve patient/family concerns.\
15. Ensure effective tracking of test results, medication management, and adherence to follow-up appointments. Maintain accurate notes and records.\
16. Develop systems to prevent errors (e.g., effective medication reconciliation).\
17. Facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed.\
18. Provides mentoring/coaching of other population health and care coordination te