Care Coordination Specialist
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About The Position
The Care Coordination Specialist (CCS) for the Peninsula Regional Clinically Integrated Network (PRCIN) functions as a key member of the primary care practice team. Under the supervision of the PRCIN Care Coordination Supervisor, the CCS is responsible for providing care coordination services to moderate and high risk patients ensuring safe and effective transitions across the health care continuum to include the ambulatory care setting, hospital, home environment, and skilled nursing facilities. The CCS serves as a care resource and coach with a focus on the health and wellness, prevention, and social determinants of health, and in collaboration with the practice-based health care team develops and implements a patient-centered plan of care that promotes self-care. The primary Duties of the Position include practice-based care coordination for patients at risk for health deterioration, poor outcomes, and/or high resource utilization, and identifying social, environmental, and financial needs and coordinating referral to community resources as appropriate. The Care Coordination Specialist will motivate patients to complete specific health care tasks related to an improvement in health, as well as provide disease specific education to assist patient in self-management of condition. They will also be responsible for the collection and analysis of data relating to team and population health metrics.
