Care Coordinator
Reporting to the RN Care Manager, a Care Coordinator works collaboratively with the care team to provide ongoing support and communication to Chronic Kidney Disease (CKD) and ESRD patients. The Care Coordinator acts as a single point-of-contact to coordinate resources along the care delivery spectrum, identify gaps, and provide proactive follow-up. The Care Coordinator is responsible for making sure the patient’s care at various locations is connected and there are no gaps in care or communication.
Essential Functions
- Performs outbound calls to patients to understand their clinical needs and connect them with appropriate resources
- Performs outbound calls to providers to make appointments for patients or follow up on care
- Answers inbound calls from patients, providers, and other resources
- Follows up with patients to ensure their needs are met and schedules future check-ins
- Coordinates with clinical resources and providers to ensure smooth continuum of care for patients.
- Monitors patient hospitalizations and follows up as necessary with care team members and outside resources to confirm Strive gathers all relevant patient information
- Notifies patients of location and appointment times as needed
- Ensures all patient records are up to date
- Provides patients with education materials and sends communications to primary care physicians, nephrologists, and specialists for new enrollments/appointments
- Assists with the referral process when needed
- Provides excellent customer service and treats patients with respect
- Help patients and their families navigate the healthcare system and multitude of visits
- Fosters a relationship with patients across their healthcare journey with a foundation of respect, honesty, empathy, no judgement and follow-through
- Skilled and passionate caring for patients with complex needs
- Collaborates well with all levels of a clinical team (from Medical Assistants to Physicians)
- Partners closely with the Strive NP to manage all pieces of care related to resources, appointments, care transitions, and care gaps
- Performs vital signs
- Meet in person with internal and/or external stakeholders to facilitate team and business priorities/opportunities.
- Serve patients in person and in multiple care settings (e.g., patient home, clinics) in addition to virtual visits.
- Home visits as determined by business need in market.
- Complete in person visits with members (in home or where convenient to patient).
- Serve as liaison between multiple service providers.
- Assist with enrollment in services and community resources.
- Assist with completing applications for resources, paperwork for provider visits, etc.
- Follow up on referrals for pharmacy, DME, home care, etc.
- Assist with finding and scheduling transportation.
- Deliver culturally competent care.
Minimum Qualifications
- High school diploma or equivalent required
- At least two (2) years of experience in a professional office environment
- Active Basic Life Support or CPR Certification
- Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms
Preferred Qualifications
- Customer service experience
- Active Community Health Worker Certification (CHW)
- Intermediate proficiency in MS Word, Excel, PowerPoint, and Outlook
- Excellent verbal and written communication skills
- Skilled at dealing with confidential information and/or issues using discretion and judgment
- Communicates clearly, respectfully, and thoughtfully
Hourly Range: $22.25-$25.00
