Care Management Referral Coordinator

St. Elizabeth Healthcare•Erlanger, KY

About The Position

The Care Management Referral Coordinator (CMRC) reports to the Manager of Care Coordination and provides telephonic and face-to-face care management interventions. The role manages the Care Management Referral Line and Referral Queue and coordinates the SEP Grant Funded Transportation Assistance program. The coordinator may also support referral audits, Health Maintenance and care-gap closure, and Social Drivers of Health interventions. Working closely with the care team, the CMRC helps patients access appropriate care and community resources, coordinates services, and monitors progress. The position is often a patient's initial contact with the Care Management Team, so it calls for critical thinking, professional judgment, organization, knowledge of care management, and strong interpersonal and Motivational Interviewing skills. The coordinator helps facilitate and maintain improved health outcomes for the community.

Requirements

Bachelor's degree in a related field, or an associate degree with equivalent experience.
At least 2 years of experience in a health-related or community resources field.
Valid driver's license, reliable transportation, and current automobile insurance.
Working knowledge of Excel, Windows, and Outlook, with the ability to learn other computer skills as needed.

Nice To Haves

Bachelor's degree in Human Services.
Care Management experience.

Responsibilities

Answer calls to the Care Management Referral Line and provide appropriate resolution.
Review incoming Care Management referrals through chart review, evaluate them, and assign or route them appropriately.
Conduct initial evaluations and assessments to determine the appropriate care team member for referrals.
Proactively identify and create appropriate referrals.
Communicate with patients, families, providers, and community resources to coordinate services and meet patient needs.
Inform care plan team members about incoming referrals as indicated.
Schedule, cancel, and reschedule appointments for the Care Management Team based on patient needs.
Connect individuals and families with community resources, coordinate services, and monitor progress.
Educate patients about resources, timelines, and goals that support accountability and collaboration.
Follow SEP Grant Funded Transportation Assistance policies and procedures; complete paperwork; coordinate cost-effective assistance; and document and track assistance.
Manage an assigned roster of patients referred or connected through warm handoffs.
Gather relevant information through chart review and patient assessment, collaborate with the healthcare team, and implement plans for desired outcomes.
Educate, schedule, and coordinate Health Maintenance and care-gap closure.
Evaluate Social Drivers of Health barriers and follow workflows to address or coordinate their resolution.
Complete face-to-face visits when necessary, in a primary care provider's office or community setting.
Coordinate care plans for Social Drivers of Health and transportation assistance with patients, families, and care teams.
Complete accurate and timely documentation and follow-up, while communicating in accordance with HIPAA guidelines.
Provide education about St. Elizabeth Physicians and community support services.
Participate in multidisciplinary care collaboratives, patient reviews, department meetings, and huddles.
Build rapport and serve as a liaison between patients, families, and healthcare teams; resolve issues constructively and maintain professional boundaries.
Network with community agencies, assist with patient requests in a timely manner, and contribute to collaboration, safety, and quality care.
Maintain role-related skills and knowledge, participate in professional development opportunities, and engage with continuous improvement and performance metrics.
Perform other duties as assigned.