30+ Days ago
Round Rock, TX
1 day ago
The Health Coordinator 1 facilitates patient continuity of care with the healthcare team. This position is responsible for utilizing available resources to ensure patients receive care that is continuous, comprehensive and coordinated across the care continuum. This position works cooperatively with providers and personnel to accomplish goals and objectives in accordance with established policies and procedures.
ESSENTIAL FUNCTIONS OF THE ROLE
Reviews reports to identify patient with past due adult preventative, diabetes and other identified clinical services; reviews the patient's electronic health record. Analyzes and compiles reports to support care coordination activities.
Facilitates care coordination with multiple teams, disciplines or external resources as required. Identifies and facilitates referrals to community resources (i.e. food, transportation, medication assistance, caregiver needs) as requested.
Contacts patients to recommend needed services, schedules office appointments and pends orders and referrals for providers to sign. Addresses patient and family concerns.
Assists patients with self-management through approved, evidence-based education, telephonic engagement, encouraging and supporting patient adherence to their care plans as requested.
Monitors the patient transition from hospital to home and back to primary care physician (PCP). Contacts the patient to ensure completion of follow up activities. Notifies the PCP and clinical office staff of issues pertinent to patient care.