The Care Coordinator manages communications, schedules, and assures physician order fulfillment for a specified group of patients. Works collaboratively and directs the flow of information of a multidisciplinary patient care team. Provides patient care interventions under the supervision of an RN.
- With unyielding conviction, conveys the Triangle of Care as our care model. Facilitates the translation of the Triangle of Care into practice.
- Performs coordination of care for an assigned group of multidisciplinary patient care teams in collaboration with a Field Case Manager.
- Assures the appropriate scheduling of patient care services according to physician orders as well as employment status and qualifications of clinicians.
- Accurately receives, records, and enters physician’s orders into the software system with correct format, spelling and grammar. Orders are processed in a timely manner.
- Provides appropriate and timely follow up to patient of care issues. Uses established forms to document patient care issues, interventions, actions and responses.
- Receives daily confirmation of critical visits from nurses and therapists. Prompts clinicians for complete information and questions for clarification on information that is incomplete or unclear. Documents information received according to set procedures.
- Communicates critical information to physicians, field staff, Care Transition Coordinators, office staff and Manager, as appropriate. This may include lab results, notification of schedule changes, admissions, hospitalizations, changes in patient condition, changes in physician’s orders, etc.
- Communicate effectively with Vital Station clinicians, patients, and field staff regarding telemonitor trends and troubleshooting
- Participates in preparation of information for case conference of an assigned group of patients. Provides medical record review and assists in transferring information to the 60 day summary prior to case conference.
- Assures appropriate discharge planning as well as the provision of State and Federally mandated patient notifications of care changes and discharges planned.
- Perform visits as dictated by the Agency’s needs
- Participate in Performance Improvement activities
- Other duties as assigned