Geriatric Care Navigator: Transitions & CCM Plans

Eventus WholeHealth; Concord (AL); Sur place; USD 42 000 - 65 000; Plein temps

Résumé du poste

Eventus WholeHealth is seeking a Care Coordinator to implement patient navigation by managing caseloads, coordinating primary and specialty care, and overseeing transitions of care for patients in our network. You will collaborate with schedulers to ensure timely follow ups and support interdisciplinary teams with post-visit updates and family communications.

Responsibilities include medication reconciliation, CCM/BHI care plan creation, documentation in the EHR, and outreach to reduce missed

Qualifications

• LPN degree or certified MA with 5 years primary care experience
• 2 years minimum experience in the LTC/ALF setting
• Care coordination experience preferred
• Value based care experience ideal
• Strong understanding of cultural competency with the target population
• Competency with Excel, PCC, Matrix and Microsoft products with the ability to become proficient with company specific programs and software.
• Interest in working with geriatric clients

Responsabilités

• Client Caseload Management
• Assist with delivering quality care for patients with chronic conditions by providing critical insights and valuable data to Eventus care teams
• Calling patient family members/POAs/caregivers to provide update post provider visits with clinical updates
• Provide day-to day support and supervision of care – ensuring labs, specialty notes, hospital and SNF records are available in EHR for provider review
• Review patients’ medical history and information from all available information sources including both internal care team and outside providers and services
• Performs medication reconciliation after a transition of care and summary of SNF/hospital stay
• Create Chronic Care Management (CCM) and Behavioral Health Integration (BHI) care plans in conjunction with the billing/rendering providers to include medications, diagnosis, patient goals and interventions, care team members, barriers, and patient education. Ensures that care plans are updated as necessary
• Ensuring that the recommendations of the care plans are being adhered to and that proper treatment and therapies are being followed.
• Refers patients to needed services, such as specialist referrals
• Calls patients/POAs/caregivers within 48 hours after a discharge from a hospital or SNF to check in and schedule a follow up visit
• Facilitate discussions with health care providers to discuss client Care Plans, transitions of care, medication reconciliation, family input and specialty referrals
• Document client services in patients chart, including updated history and medication reconciliation from their transition of care, summary of information discussed during phone calls, etc.
• Track client information and appointments in a confidential manner
• Initiate outreach and missed appointment procedures, as necessary
• Assist in disseminating tasks needed by providers to achieve quality metrics for value based care programs
• Assist with coordinating physician visits with scheduling for LTC ACO and follow up appointments within 1 week for ACO reach patients after a transition of care
• Track time spent in care coordination activities to document for chronic care management minutes
• Ensure that all Medicare requirements of the CCM and BHI programs are being adhered to.
• Other duties as assigned.

Connaissances

Communication skills

Geriatrics knowledge

Organization

Time management

Patient navigation

Interpersonal skills

Formation

LPN degree

Certified MA with 5 years primary care experience

Outils

Excel

PCC

Matrix

Microsoft Office

Description du poste

Eventus WholeHealth is seeking a Care Coordinator to implement patient navigation by managing caseloads, coordinating primary and specialty care, and overseeing transitions of care for patients in our network. You will collaborate with schedulers to ensure timely follow ups and support interdisciplinary teams with post-visit updates and family communications.

Responsibilities include medication reconciliation, CCM/BHI care plan creation, documentation in the EHR, and outreach to reduce missed