Job Description

Summary/

Objective

The Care Coordinator is a core member of the care team, including the patient's medical provider and psychiatric consultant, and the larger primary care team. The Care Coordinator is responsible for supporting and coordinating the overall health of patients, with a focus on chronic conditions, preventative care, and healthy behaviors.

Essential Functions

Communicates to patients the purpose of the program and the impact it may have on their wellbeing. Helps patients identify social determinates of health that affect their overall health and develop health and social management plans and goals. Educates the patient on the proper use of the emergency room and provides information for alternatives. Assists patients in understanding care plans and instructions. Motivates patients to be active and engaged participants in their health and overall wellbeing. Responsible for developing a comprehensive individualized plan of care and targeted interventions incorporating the patient's preferences and SMART goals. Effectively communicates with the patient's care team / PCP to exchange information about the patient and give updates on progress made with self-management support services. Ensures age applicable health assessments/screenings are completed timely and documented in the electronic health record appropriately. Continual development of knowledge and understanding of community resources, NorthShore services, and programs offered. Completing transitions of care for ER/IP visits for patients within 72 hours of discharge and documenting findings appropriately in the patient's electronic health record. Closing the loop on all external referrals and obtaining outside records and results. Addressing gaps in care and documenting results in the patient's electronic health record. Assists with patient/provider requests for durable medical equipment, home health services, FMLA requests, etc. Completes glucose testing, Continual Glucose Monitoring Device (CGM) placements, basic vitals, and other tests assigned by management. Provides follow up to patients to find out if they are meeting goals and how they are managing health issues, celebrates successes, and provides suggestions to overcome barriers to care. Maintains top quality proficiencies across all training areas in daily work. Attends meetings and training sessions as required.
Executes other assigned tasks as requested by management.
These essential functions are a summary of the primary duties and responsibilities of the position and are not intended to be a comprehensive listing of all duties and responsibilities. The position will include other duties as assigned and duties are subject to change at the management's discretion.

Competencies

Planning and strategic foresight Responsible Decision Making and Problem Solving Integrity and accountability Innovation and creativity Adaptive and flexible Leadership, teamwork, and conflict resolution Professionalism and work ethic Empathy

Work Environment

Work is performed in an ambulatory care environment. Involves frequent personal and telephone contact with patients, physicians, and other healthcare personnel. Work may be stressful at times. Interaction with others is constant and interruptive.

Travel

Travel outside of Northshore locations will be rare for this position.

Required Role Qualifications

Minimum required education per state of Indiana/HRSA*
1 year of care coordination experience Community Health Worker Certification within 1 year of hire Valid CPR certification

Preferred Role Qualifications

Two years of experience working within a healthcare setting.*
Certified/Registered Medical Assistant, Licensed Practical Nurse, Advanced Practical Nurse or Registered Nurse licensing Bilingual preferred

Required Skills

Ability to analyze situations and solve problems at strategic and tactical levels Excellent interpersonal and customer service skills Ability to comprehend, interpret, and apply the appropriate sections of applicable laws, guidelines, regulations, ordinances, and policies Ability to acquire a thorough understanding of the organization's hierarchy, jobs, qualifications, compensation practices, and the administrative practices related to those factors Practiced at organization and planning Employ Critical thinking and problem solving Maintains composure and operates with emotional intelligence Ethical reasoning and decision-making Strong attention to detail Receptive and responsive to feedback Excellent verbal and written communication skills Time management, prioritization, and sense of urgency Proficient with Microsoft Office Suite or related software

Physical, Visual, and Audible Requirements

Physical Requirements

Activity

Occasionally (1 -33%)

Frequently (34-66%)

Continuously (67-100%)

Sitting




X







Walking




X







Standing




X







Bending


X







Squatting/
Crouching



X







Climbing


X







Kneeling


X







Twisting/Turning




X







Hand dexterity/Fine Motor Manipulation




X



Lifting 0 - 50lbs


X







Lifting 50+lbs


X







Carrying 0 - 50lbs




X







Carrying 50+lbs




X







Pushing 0 - 300lbs


X

Visual & Audible Requirements -

Employee mark an "x" for "YES" or "NO"

Activity

Yes

No

Can see without corrective eyewear







Can differentiate colors/see color differences clearly







Can hear without hearing assistance







I acknowledge that I may be exposed to infectious and contagious diseases. I acknowledge that I may be in contact with patients under a wide variety of circumstances. I acknowledge that I can handle and respond to emergency or crisis situations per NorthShore Health Centers facility plans, protocols, and procedures. I acknowledge that I may occasionally be subject to irregular working hours. I acknowledge that I may be required to wear personal protective equipment (PPE) as necessary.



* Reasonable accommodations can be made to enable people with disabilities to perform the essential functions of the job described.