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Presbyterian is hiring a skilled Care Coordinator II to join our care team. You will coordinate care across hospital, clinic, and home settings, working with interdisciplinary teams to ensure quality, cost-effective services and strong patient outcomes.
The role supports patients with chronic conditions, conducts assessments, and develops care plans including transitions to home and community-based services.
211 Sudderth Dr Ruidoso, NM 88345-6002
Build your Career. Make a Difference. Presbyterian is hiring a skilled Care Coordinator II
How you grow, learn and thrive matters here.
Full time
0.90
No
10 Hour Days (United States of America)
Facilitates a team approach, including the Interdisciplinary Care Plan team, to ensure appropriate interventions, cost effective delivery of quality care and services across the continuum. Collaborates with the interdisciplinary care plan team which may include member, caregivers, members legal representative, physician, care providers, and ancillary support services to address care issues, specific member needs and disease processes whether, medical, behavioral, social, community based or long term care services. Coordinates care of individual clients with application to identified populations using assessment, care planning, implementations, coordination, monitoring and evaluation for cost effective and quality outcomes
Some key responsibilities include
Supports patients in a hospital and inpatient or clinic setting
Facilitates a team approach, including the Interdisciplinary Care Plan team, to ensure appropriate interventions, cost effective delivery of quality care and services across the continuum. Collaborates with the interdisciplinary care plan team which may include member, caregivers, member s legal representative, physician, care providers, and ancillary support services to address care issues, specific member needs and disease processes whether, medical, behavioral, social, community based or long term care services.
Provides care coordination to members with chronic condition with less complex needs including less community resources. Conducts in depth health risk assessment and/or comprehensive needs assessment which include but not limited to psycho-social, physical, medical, behavioral, environmental, and financial parameters. Develops and communicates plan for authorization of services, and serves as point of contact to ensure services are rendered appropriately, i.e. during transition to home care, back up plans, community based services.
Assesses and reviews plan of care regularly to identify gaps in care, trends to improve health and quality of life outcomes; collects clinical path variance data that indicates potential areas for improvement of case and services provided; works with members and the interdisciplinary care plan team to adjust plan of care, when necessary.
Implements, coordinates, and monitors strategies for members and families to improve health and quality of life outcomes. Develops, documents and implements plan which provides appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs. Acts as an advocate for member s care needs by identifying and addressing gaps in care. Performs ongoing monitoring of the plan of care to evaluate effectiveness. Measures the effectiveness of interventions as identified in the members care plan.
Provides assistance to members with questions and concerns regarding care, providers or delivery system.
Conducts face to face home visits, as required.
Educates providers, support staff, members and families regarding care coordination role and health strategies with a focus on member focused approach to care. Facilitates a team approach to the coordination and cost effective delivery to quality care and services.
Maintains professional relationship with external stakeholders, such as inpatient, outpatient and community resources.
Promotes the appropriate use of clinical and financial resources in order to improve the quality of care and member satisfaction. Generates reports in accordance with care coordination goals.
Participates in Interdisciplinary Care Team (ICPT) meetings.
Assists with orientation and mentoring of new team members as appropriate.
Performs other functions as required.
Associates Degree, 3 years of additional experience can be substituted in lieu of an Associates Degree. Bachelors degree preferred.
2 years of related experience.
Must have a valid driver license, clean driving record, and able to travel locally.
Experience in utilization management, quality assurance, home care, community health, long term care or occupational health required.
CCM certification preferred or must obtain