Geriatric Care Navigator & Transitions Lead

Eventus WholeHealth; Chapel Hill (NC); On-site; USD 52,000 - 70,000; Full time

Job summary

Eventus WholeHealth in Chapel Hill, NC seeks a Care Coordinator to manage patient caseloads, coordinate primary and specialty care, and oversee transitions of care in a geriatric-focused program. You will collaborate with patient schedulers to ensure timely follow-up appointments.

This role emphasizes documenting patient interactions in the EHR, conducting medication reconciliation after hospital or SNF stays, and creating CCM and BHI care plans with the care team to meet Medicare requirements.

Qualifications

• LPN degree or certified MA with 5 years primary care experience.
• 2 years minimum LTC/ALF experience.
• 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.
• Interest in working with geriatric clients.

Responsibilities

• Manage client caseloads and coordinate primary/specialty care.
• Provide insights to care teams from chronic conditions data.
• Call families/caregivers post visits with clinical updates.
• Ensure labs and notes are available in the EHR for review.
• Review medical history from internal and external sources.
• Perform medication reconciliation after transitions of care.
• Create CCM and BHI care plans with providers and care team.
• Track adherence to care plans and follow-up treatments.
• Refer patients to needed services and specialists.
• Coordinate LTC/ACOs follow-ups within 1 week after discharge.
• Document services in patient charts and maintain confidentiality.
• Track time in care coordination for CCM minutes.
• Ensure Medicare CCM and BHI program compliance.
• Other duties as assigned.

Skills

Care coordination

Excellent communication

Geriatric care knowledge

Confidentiality & documentation

Time management

Relationship building

Team collaboration

Education

LPN degree or certified MA

5 years primary care experience

2 years LTC/ALF experience

Tools

Excel

PCC

Matrix

Microsoft Office

Job description

Eventus WholeHealth in Chapel Hill, NC seeks a Care Coordinator to manage patient caseloads, coordinate primary and specialty care, and oversee transitions of care in a geriatric-focused program. You will collaborate with patient schedulers to ensure timely follow-up appointments.

This role emphasizes documenting patient interactions in the EHR, conducting medication reconciliation after hospital or SNF stays, and creating CCM and BHI care plans with the care team to meet Medicare requirements.