SENTARA CARE COORDINATOR (3654)

CVHS HEALTH SERVICES•Petersburg, VA

12d•$23 - $29•Hybrid

About The Position

Patient care coordinators are liaisons between patients and the healthcare system. As a patient care coordinator, you would ensure that patients receive the care they need and that they understand their medical condition, medications, and other instructions. Identify high-risk individuals by working with and while supporting Sentra’s insurance plan and via CVHS electronic record/practice management information. Perform regular outreach based on the patient’s personal preference, which could include email (if secure) or phone calls. Assists Sentara’s identified cohorts of patients through the healthcare system by acting as a patient advocate and navigator. Works closely with the Case Manager, Patient Educator, and others who assess the patient, to coordinate patient's care and establish a plan of care. Supports patient self-management of disease and behavior modification interventions. Coordinates continuity of patient care with external healthcare organizations and facilities, by assuring all patient records are submitted to the Primary Care Provider. Helps to manage high risk patient care, including patients with co-morbidities or high risk for readmission to a hospital setting, including a registry. Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans. Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation related to the Patient-Centered-Medical Home model. Customize care plans to meet the individual patient’s needs, prioritizing goals for patient’s health status; establish timeframes for re-evaluation; identify resources to be utilized, including the appropriate level of care; plan for continuity of care, including transition of care; identify collaborative approaches to be used, including family participation. Work with the patient, their family and/or caregivers to identify self-management support. Effectively research and resolve prescription processing rejections to ensure patients receive medications within established patient service standards. Work closely with other pharmacy teammates to ensure all orders are received and processed timely and accurately. Receives calls from patients and answers questions regarding prescription status, reimbursement, co-payment assistance, health plan drug coverage, and other related questions. Maintains patient database information including personal, physician, prescription, insurance, agency, financial assistance and related data. Work in a hybrid capacity with scheduled coverage at the mobile health unit 2–3 days per week. Participates in Quality Assessment Participates in Clinical Collaboratives Documents each patient encounters, in the electronic health record. Supports a team-based approach to patient-centered medical care. Attends work as scheduled. Managers may modify, add or remove essential job functions as necessary, or as changing organizational needs require. Complete annual competencies for current position, basic hands-on nursing skills for patient care. Attend annual skills day offered for nursing staff. Assist with patient care within the site in the event of a catastrophic nursing shortage and when all other resources have been utilized. Performs other duties as assigned.

Requirements

Graduate of an accredited school of nursing.
Licensed by the Virginia State Board of Nursing, or from a compact state.
Data entry, retrieval, and report generation experience.
3 years in office clinical experience.

Nice To Haves

Demonstrates competence in performing essential duties.
Ability to plan.
Concern for patient confidentiality.
Shows initiative and ability to use sound judgment in the absence of specific orders.
Resourceful Patient Advocate.

Responsibilities

Act as a liaison between patients and the healthcare system, ensuring patients receive necessary care and understand their medical conditions, medications, and instructions.
Identify high-risk individuals by working with Sentra’s insurance plan and via CVHS electronic record/practice management information.
Perform regular outreach to patients based on their personal preference (email or phone calls).
Assist identified patient cohorts through the healthcare system as a patient advocate and navigator.
Coordinate patient care with Case Managers, Patient Educators, and other healthcare professionals.
Support patient self-management of disease and behavior modification interventions.
Coordinate continuity of patient care with external healthcare organizations and facilities, ensuring all patient records are submitted to the Primary Care Provider.
Manage high-risk patient care, including patients with co-morbidities or high risk for readmission.
Promote clear communication among the care team and clinicians regarding patient care plans.
Participate in data collection, health outcomes reporting, clinical audits, and programmatic evaluation for the Patient-Centered-Medical Home model.
Customize care plans to meet individual patient needs, establish re-evaluation timeframes, identify resources, and plan for continuity of care.
Collaborate with patients, families, and caregivers to identify self-management support.
Research and resolve prescription processing rejections to ensure timely medication delivery.
Process orders accurately and timely.
Answer patient calls regarding prescription status, reimbursement, co-payment assistance, and health plan drug coverage.
Maintain patient database information, including personal, physician, prescription, insurance, agency, and financial assistance data.
Work in a hybrid capacity, with scheduled coverage at the mobile health unit 2-3 days per week.
Participate in Quality Assessment and Clinical Collaboratives.
Document each patient encounter in the electronic health record.
Support a team-based approach to patient-centered medical care.
Attend work as scheduled.
Complete annual competencies for the current position and basic hands-on nursing skills.
Attend annual skills day offered for nursing staff.
Assist with patient care during a catastrophic nursing shortage when all other resources are utilized.
Perform other duties as assigned.