Care Coordinator

Fair Haven Community Health Care•New Haven, CT

About The Position

We are seeking a Care Coordinator to join our dynamic team! Job purpose The Care Coordinator is a vital member of the interdisciplinary patient care team. This role provides patient navigation and facilitates access to care, based on EHR data and referrals from clinical teams. The Care Coordinator identifies any barriers that may impact a patients access to health care, and will link them to appropriate services. Duties and responsibilities Reporting to the Care Coordination Program Manager, the Care Coordinator’s role will involve in-person visits with patients and families as well as telephonic visits. Patients who have been identified as needing additional support services to navigate the healthcare system and access community resources, , high utilizers of acute care or hospital services, or otherwise high-needs/high-cost patients, will comprise the panel of patients the Care Coordinator will address through measurable efforts to improve health and adherence/access to health care.

Requirements

Associates Degree in a health-related field and/or relevant years of experience is required
a valid CT driver’s license and/or access to reliable transportation is also required
Experience in Care Coordination; working with teams; using EPIC electronic health record highly preferred
The successful candidate will have excellent computer skills including word processing and data entry required and the ability to work independently.

Nice To Haves

Bachelor’s degree preferred
Bilingual in English and Spanish is highly desirable

Responsibilities

Outreach to patient populations based on gaps-in-care reports or other reports that have identified vulnerable patients and families
Conduct needs assessments at least yearly using a validated screening instrument on all patients with whom the Care Coordinator interacts
Develop and evaluate shared plans of care
Link patients with barriers to community resources
Assist with and follow-up on the successful completion of health maintenance items (e.g. lab testing, annual visits) and chronic disease management (e.g. routine diabetic or asthmatic care)
Conduct home visits as needed
Identify barriers to care impacting patients’ abilities to adhere to treatments
Assist patients with insurance enrollment, or other patient assistance programs
Work collaboratively with clinical teams to meet the need of complex, high-cost patients
Attend relevant trainings as required and assigned
Document client referrals, encounters, and services in the EPIC electronic health record and communicate securely with other team members and clinicians
Maintain strict adherence to all deadlines including report deadlines and timely completeness of documentation