Care Coordinator

NORTHSHORE HEALTH CENTERS•Lake Station, IN

23h•Onsite

About The Position

The Care Coordinator is a core member of the care team, including the patient’s medical provider and psychiatric consultant, and the larger primary care team. The Care Coordinator is responsible for supporting and coordinating the overall health of patients, with a focus on chronic conditions, preventative care, and healthy behaviors.

Requirements

Minimum required education per state of Indiana/HRSA
1 year of care coordination experience
Community Health Worker Certification within 1 year of hire
Valid CPR certification
Ability to analyze situations and solve problems at strategic and tactical levels
Excellent interpersonal and customer service skills
Ability to comprehend, interpret, and apply the appropriate sections of applicable laws, guidelines, regulations, ordinances, and policies
Ability to acquire a thorough understanding of the organization's hierarchy, jobs, qualifications, compensation practices, and the administrative practices related to those factors
Practiced at organization and planning
Employ Critical thinking and problem solving
Maintains composure and operates with emotional intelligence
Ethical reasoning and decision-making
Strong attention to detail
Receptive and responsive to feedback
Excellent verbal and written communication skills
Time management, prioritization, and sense of urgency
Proficient with Microsoft Office Suite or related software
Can see without corrective eyewear
Can differentiate colors/see color differences clearly
Can hear without hearing assistance
May be exposed to infectious and contagious diseases.
May be in contact with patients under a wide variety of circumstances.
Can handle and respond to emergency or crisis situations per NorthShore Health Centers facility plans, protocols, and procedures.
May occasionally be subject to irregular working hours.
May be required to wear personal protective equipment (PPE) as necessary.

Nice To Haves

Two years of experience working within a healthcare setting.
Certified/Registered Medical Assistant, Licensed Practical Nurse, Advanced Practical Nurse or Registered Nurse licensing
Bilingual preferred

Responsibilities

Communicates to patients the purpose of the program and the impact it may have on their wellbeing.
Helps patients identify social determinates of health that affect their overall health and develop health and social management plans and goals.
Educates the patient on the proper use of the emergency room and provides information for alternatives.
Assists patients in understanding care plans and instructions.
Motivates patients to be active and engaged participants in their health and overall wellbeing.
Responsible for developing a comprehensive individualized plan of care and targeted interventions incorporating the patient’s preferences and SMART goals.
Effectively communicates with the patient’s care team / PCP to exchange information about the patient and give updates on progress made with self-management support services.
Ensures age applicable health assessments/screenings are completed timely and documented in the electronic health record appropriately.
Continual development of knowledge and understanding of community resources, NorthShore services, and programs offered.
Completing transitions of care for ER/IP visits for patients within 72 hours of discharge and documenting findings appropriately in the patient's electronic health record.
Closing the loop on all external referrals and obtaining outside records and results.
Addressing gaps in care and documenting results in the patient’s electronic health record.
Assists with patient/provider requests for durable medical equipment, home health services, FMLA requests, etc.
Completes glucose testing, Continual Glucose Monitoring Device (CGM) placements, basic vitals, and other tests assigned by management.
Provides follow up to patients to find out if they are meeting goals and how they are managing health issues, celebrates successes, and provides suggestions to overcome barriers to care.
Maintains top quality proficiencies across all training areas in daily work.
Attends meetings and training sessions as required.
Executes other assigned tasks as requested by management.