Outpatient Care Coordinator

Outpatient Care Coordinator
Job ID
Agawam, Massachusetts
Full/Part Time
Baycare Health Partners is seeking an Ouptatient Care Coordinator at Riverbend Group in Agawam, MA.
Under the direction of the Director, Clinical Integration, responsible for a wide variety of duties related to medical outreach to patients and medical data entry. Major responsibilities/accountabilities to include outreach to patients in a professional, respectful manner; work collaboratively with the practice based care manager, manage patient lists, and to accurately and efficiently enter data. Specific duties may include:
Communicates and coordinates with all entities involved in the care of a patient to promote and maximize care coordination and patient satisfaction for a population of patients. Follows up with patients that have been in the Emergency Department/Inpatient to facilitate PCP follow up and identify unmet needs, under the direction of the Care Manager. Maintains clear, concise, objective and accurate documentation of patient encounters. Conducts Health Risk Assessments and Orientations to the practice and refers patients appropriately to the Care Manager. Screens/Identifies/Outreaches to patients to assure needs for preventive care and disease management are met. Performs home visits, if applicable, to a subset of patients. Assists the practice Care Manager in managing a Quality Improvement committee at the practice. Develops and implements a personal development program to ensure continuing professional growth. Observes all health and safety requirements
What You Will Do:
Develop and maintain excellent working relationships with patients, physicians and their practice staff, as well as other Care Coordinators along the continuum (e.g., inpatient, post acute).
Population Management: Utilize registries as well as standing orders to proactively identify and outreach to patients that are in need of preventive screenings/chronic disease testing. Assist patients in scheduling appointments and tracking until the results are received.
Transitions of Care: Provide outreach calls, per protocol, to patients that have been discharged from the hospital or the emergency room. Review discharge instructions, ensure follow up appointments are made, screen for care management.
Care Coordination: Provide ongoing support and coaching to a subset of patients needing care coordination, resource linkage, self-management support.
Link patients to community resources and track to ensure services are in place.
Work in collaboration with the Nurse Care Manager to ensure care coordination activities are provided to maximize outcomes for the patient.
Participate in practice as well as Care Management team meetings.
Prescreens patients for complex care management utilizing a Health Risk Assessment.
Provides, clear, concise documentation in the patients Medical Record.
Performs home visits, if applicable, to a subset of patients.
What You Will Need:
Minimally Required Education: Graduate of an accredited MA program
Preferred Education: Associate's Degree
Minimally Required Experience: Certified by American Association of Medical Assistants (AAMA) or Registered through Medical Assistant (RMA)
Skills / Competencies:
Required: Excellent written and verbal communication and interpersonal skills are a must. Capacity to work closely with patients, physicians and their office staffs and managed care plans. Strong organizational and prioritization skills. Attention to detail and able to perform work independently
License: Driver's License is required
Equal Employment Opportunity
Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.

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