Community Care Coordinator - Grace Medical Center
Baltimore, MD
GRACE MEDICAL CENTER
FAM H&W CENTER
Full-time - Day shift - 8 : 30am-5 : 00pm
Allied Health
83356
Posted : May 8, 2024
Apply Now
Setting the Saved Jobs link function setsavedjobs(externalidlist) if(typeof externalidlist ! 'undefined') var saved jobs query ' / jobs / search?
externalidlist.replace( / - - / g,'&external id ')+'&saved jobs 1'; var saved jobs query sub saved jobs query.replace(' / jobs / search?
replace('&saved jobs 1',''); if (saved jobs query sub ! '') $('.saved jobs link').attr('href',saved jobs query); else $('.
saved jobs link').attr('href',' / pages / saved-jobs'); var is job saved 'false'; var job saved message; function savejob(jobid) var job item;
if (is job saved 'true') is job saved 'false'; job item ''; $('.saved-jobs-alert check').toggleClass('removed'); $('.saved-jobs-alert message').
html('Job has been removed.'); else is job saved 'true'; job item ''+' '+jobid; $('.saved-jobs-alert check').toggleClass('removed');
$('.saved-jobs-alert message').html('Job has been saved!'); document.cookie "c jobs "+job item+';expires ;path / '; $('.
button-saved, .button-save').toggleClass('d-none'); $('.button-saved').append('
$('.saved-jobs-alert-wrapper').fadeIn(); setTimeout(function() $('.button-saved').html('Saved'); $('.saved-jobs-alert-wrapper').
fadeOut(); , 2000); / / Setting the Saved Jobs link - function call setsavedjobs(job item);
Save Job Saved
Summary
JOB SUMMARY :
The primary responsibility of the Community Care Coordinator working under the oversight of assigned Community Care Manager or Supervisor is to promote the health and welfare of assigned patients through face to face and / or phone outreach and e-mail communications.
The Community Care Coordinator is a member of Interdisciplinary Team (IDT) caring for the patient in ensuring the patient’s individual needs are identified and addressed in a timely manner, act as patient advocate to address primary physical and social needs including assessing and linking community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family.
- Accountable for contacting patients, caregivers and families to ensure preventive services are received by assigned patients
- Decrease identified care gaps by working with primary care offices to obtain timely appointments for assigned patients including Post-hospital discharge and Annual Wellness Visits where appropriate
- Understand and apply principles of population health management to identify patients with uncontrolled chronic conditions and / or rising risk indicators and refer to Community Care Manager accordingly
- Provide care coordination services for patients requiring chronic care management
- Ensure that appropriate patients receive annual physical exam and / or annual health risk assessment (HRA) including completion of required documentation by payer contract
- Evaluates and refers patients to Community Care Manager, as appropriate, when acuity changes
- Follow treatment plans of patient as written by provider and / or Community Care Manager
- Where appropriate, assesses patient in the home environment and assist the IDT to evaluate the patient’s needs in their home to facilitate the patient’s ability to improve self-management skills.
- Leads the IDT discussion in home management of assigned patients including facilitation of home care referrals where appropriate
- Where appropriate, facilitate discussion with patient and family members on advance directives.
- Provides expertise in linking patients with community resources such as prescription assistance
- Assist patients in navigating social and health services such as enrollment in social security, Medicaid, Medicare, and other appropriate insurance plans
- Assesses and assist patient’s safety needs in home, i.e. fall risk and order equipment where necessary to promote patient independence
- Assist with self-management of medication, i.e. setting up medication boxes if needed.
- Refer patient or family to community resources for housing or treatment to assist in recovery from chronic illness and following through to ensure service efficacy.
- Educate and aid family members to assist them in understanding, dealing with, and supporting the patient with a chronic illness and end of life practices
- Interview clients about activities of daily living to determine needs and link with community resources where appropriate
- Reviews and updates Provider and Community Care Manager of patients’ living conditions and ability to adhere to plan of care and coordinate treatment goals
- Assess, monitor, and evaluate, the patient’s progress in the home with respect to treatment goals.
- Documents findings in health care record following System approved protocols.
- Perform the tasks necessary for collecting data, maintaining records, developing, and utilizing assessment and measuring tools relative to patient care and wellness practices.
- Obtain and coordinate access with primary care providers and other specialty providers including behavioral health ensuring necessary records and documentation of referrals are completed and reconciled.
- Educate patients on availability of resources for primary care and acute care along with alternative community programs and services that promote sound health, lifestyle, and well-being.
- Schedule timely and appropriate office and follow-up visits at / with and or other health care providers such as dentists, public health, social services, or any other outreach workers needed to provide comprehensive and quality care for patients
- Be able to work independently with minimal supervision
- Community outreach activities as assigned
REQUIREMENTS :
- Licensed Practice Nurse or Certified Medical Assistant or trained Patient Care Assistant with 2-3 years acute care and / or ambulatory practice experience
- Preferably with experience working with care managers from acute care setting or health insurance and / or other payer entities.
- Good verbal and communication skills and organizational skills a must
- Competency in electronic medical records desirable
- Bi-lingual preferable (market specific)
Additional Information
As one of the largest health care providers in Maryland, with 13,000 team members, We strive to CARE BRAVELY for over 1 million patients annually.
LifeBridge Health includes Sinai Hospital of Baltimore, Northwest Hospital, Carroll Hospital, Levindale Hebrew Geriatric Center and Hospital and Grace Medical Center, as well as our Community Physician Enterprise, Center for Hope, Practice Dynamics, and business partners : LifeBridge Health & Fitness, ExpressCare and HomeCare of Maryland.
Share :
talemetry.share();
Apply Now
var jobsmap null;var jobsmap id "gmapobprc";var cslocations $cs.parseJSON(' "id " : "1827900 ", "title " : "Community Care Coordinator - Grace Medical Center ", "permalink " : "community-care-coordinator-grace-medical-center ", "geography " : "lat " : "39.
2879159 ", "lng " : "-76.6489083 " , "location string " : "2000 West Baltimore Street, Baltimore, MD " ');function tm map script loaded() jobsmap new csns.
- maps.jobs map().draw map(jobsmap id, cslocations); function tm load map script() csns.maps.script.load( function() tm map script loaded();
- $(document).ready(function() tm load map script(); );