Patient Care Coordinator

As a Care Coordinator, you will be responsible for a panel of patients and, in collaboration with other members of our Nephrology partners and interdisciplinary care team, help patients meet their kidney care and overall care goals. Care coordinators monitor and coordinate patients' treatment plans, educate them about their condition, connect them with health care providers, coordinate care with care centers and partners, and evaluate their progress.

PRIMARY FUNCTIONS - Establish trusting, supportive, collaborative relationships with patients and their families - Build relationships with patients in a clinical setting, working alongside the interdisciplinary team professionals, including nephrologists, nurse care managers, advanced practice providers, behavioral health advanced practice providers, pharmacists, social workers, and dietitians. Actively engage a panel of adult patients - Consistently track census on inpatient and skilled nursing facility admissions, coordinate care, ensure the proper discharge, and timely follow-up as appropriate - Closely work with NCMs on outpatient, longitudinal care coordination of in-home and community-based services, including but not limited to DME, home health, referrals, and in-home supportive services - Take responsibility (in partnership with providers and NCM) for the health of a population of patients and monitor and track whether those patients are up to date on preventive measures - Communicate with patients by phone or in person and escalate to the care team when necessary. Link patients to community resources - Assist with the coordination of care across the kidney care continuum, such as scheduling appointments with specialists and dialysis centers, coordinating referrals, and sharing or transferring information with the patient’s internal and external care team - Participate in establishing a pragmatic care plan - Capture relevant information about the patient’s health and healthcare experience, take vitals, administer point-of-care testing, and perform standard age and condition-appropriate screening assessments as needed - Other duties as assigned

required

• High School/GED

• Care Coordinator (2+ years)

preferred

• Any of the following licenses/certifications:

  • Valid Emergency Medical Technician (EMT)

  • Valid Certified Medical Assistant (CMA)

  • Valid Phlebotomy Technician Certificate (PTC)

  • Valid Certified Nursing Assistant (CNA)

All your information will be kept confidential according to EEO guidelines.