Intrinsia Health

Definition:

The Care Coordinator is responsible for driving the intake process and communicating patient needs. The Care Coordinator strives for communication excellence by bridging the gaps between patients, caregivers and all members of the care team. The Care Coordinator will assist the Providers in their appointments and care coordination needs.

This person builds a trusting relationship with patients and caregivers by understanding their critical needs and conveys that information to the care team. The Care Coordinator plays a vital role and is integral at every hand-off throughout the patient journey.

The Care Coordinator reports directly to the Director of Nursing of Intrinsia Health.

Responsibilities:

Perform all Care Coordination needs (including):

• Conduct outreach to patients and their family members to coordinate and schedule visits with the ACO REACH provider
• Develop rapport with patients, caregivers, and others in the home or facility
• Request patient H&P and clinical documents
• Conduct initial intake and review health history with patients and family in their home
• Enter and update demographics, ensure practice forms are signed, and document timely working in patient’s chart
• Measure patient vital signs, including height, weight, body temperature, blood pressure, pulse, and respirations
• Perform pre-provider screenings based on patient history and needs by obtaining personal medical data, including health history, current medications, reason for visit, etc. and recording in the medical record
• Screen patient unmet needs and review charts, labs, and self-management goals in pre-visit chart review and schedule needed services prior to visit
• Administer routine medications under physician/NPP orders, which may include but are not limited to immunizations, antibiotics, vitamins, and topical agents
• Follow up on all tasks, including open orders for e-prescribe, medication refills, DME, laboratory, specialist referrals and home health, follow up with patients across care transitions, and assist in entering medication and patient history into EHR
• Communicate accurate and timely information with patients
• Assist with accessing, scanning, and maintaining medical records
• Notify care team members when visits are not complete
• Verify that visit notes are completed within 48 hours of visit
• Create and submit super bills, following established workflows to ensure accurate and timely billing completion
• Communicate with providers and other members of the care team to ensure processes flow smoothly and make adjustments as necessary
• Notify patient’s PCP and/or practice staff of change in patient status or need for follow up
• Option to travel, including out-of-state, to contracted Participant Provider locations to support ACO REACH patient visits, foster provider and staff engagement, and ensure effective coordination of care and program initiative
• When appropriate, and in collaboration with Participant Providers, assist with Voluntary Alignment activities to support patient engagement and ACO REACH program requirements
• Assist in educating patients and families on Medicare Approved Benefit Enhancements and contracted Preferred Providers when applicable
• Assist with community education regarding Intrinsia, the ACO REACH program, and available services

Qualifications / Skills:

1. Graduate of a Medical Assistant certificate or Certified Nursing Assistant program required
2. Palliative Care / Home Health experience preferred
3. Expert customer service ability
4. Possesses an ability to maintain good interpersonal relationships with patients, families, co-workers, and other health team members
5. Learns and understands the roles of all members of the care team