Health Home Care Coord
Core
Provides professional comprehensive care management services to patients, focusing on complex, high-utilizing individuals by developing care plans and coordinating with health, behavioral health, and social service providers.
Role type
Senior care coordinator (health home)
Builds
Sustainable support systems for patients through care coordination and community resource linkage
Domain
Healthcare / Social Services
Required skills
Care plan development, patient assessment, telephonic outreach, in-person community engagement, care coordination, utilization monitoring, documentation in electronic medical records, transition of care support
Preferred skills
Experience linking people with services addressing social determinants of health
Technologies
Electronic medical records systems
Responsibilities
Develop comprehensive care plans highlighting patient goals; interact with patients via telephonic and in-person encounters in various community settings; coordinate outreach to find and retain patients; monitor service utilization and encourage adherence to treatment; partner with community providers to obtain needed services; complete timely documentation in compliance with regulations; support transitions of care and reduce unnecessary emergency/inpatient services.
Seniority
Mid-level, hands-on IC