HNE BeHealthy ACO Care Coordinator

1400 Baystate Medical Practices, Inc; United States; On-site; USD 34,000 - 47,000; Full time

Job summary

Baystate Health is seeking a Care Coordinator to support delivering high-quality, cost-effective care for patients with chronic illnesses and complex needs. You will work within an interdisciplinary team, help patients access services, and promote engagement and self-management.

The role involves coordinating referrals and transitions of care, reviewing care plans with families, and maintaining precise documentation. Home visits may be conducted as needed to ensure continuity of care.

Qualifications

• 2-5 years of experience in a medical or healthcare setting.
• Experience working with diverse populations and individuals with complex medical and social needs.
• Strong organizational, communication, documentation, and computer skills.
• Ability to work independently and collaboratively as part of an interdisciplinary team.
• Strong patient advocacy and care coordination skills.

Responsibilities

• Serve as a resource, advocate, and point of contact for patients, families, providers, payers, and community resources.
• Coordinate referrals, transitions of care, follow-up, and access to appropriate healthcare and community services.
• Collaborate with the Nurse Care Manager, providers, behavioral health, and other members of the interdisciplinary team to support comprehensive patient care.
• Review care plans with patients and families, monitor progress, and identify barriers to achieving care goals.
• Promote preventive care, self-management, and shared decision-making while helping reduce avoidable emergency department visits and hospitalizations.
• Maintain accurate and timely documentation in the medical record and track referrals, patient contacts, and follow-up needs.
• Collect and enter data to support program reporting, quality improvement, and evaluation.
• Utilize clinical, research, and quality databases as appropriate.
• Work independently while maintaining strong communication and collaboration with the healthcare team.
• May conduct home visits as needed.

Skills

Healthcare experience

Care coordination

Communication skills

Organization

Independent work

Team collaboration

Education

High School Diploma

Tools

Computer skills

Electronic Health Records

Job description

Job Summary

The Care Coordinator supports the delivery of high-quality, cost-effective care for patients with chronic illnesses and complex medical and social needs. Working as part of an interdisciplinary team, the Care Coordinator helps patients access appropriate services, navigate the healthcare system, and achieve their care plan goals. The Care Coordinator serves as a liaison between patients, families, providers, payers, and community resources while promoting effective communication, patient engagement, self-management, and continuity of care.

Key Responsibilities

• Serve as a resource, advocate, and point of contact for patients, families, providers, payers, and community resources.
• Coordinate referrals, transitions of care, follow-up, and access to appropriate healthcare and community services.
• Collaborate with the Nurse Care Manager, providers, behavioral health, and other members of the interdisciplinary team to support comprehensive patient care.
• Review care plans with patients and families, monitor progress, and identify barriers to achieving care goals.
• Promote preventive care, self-management, and shared decision-making while helping reduce avoidable emergency department visits and hospitalizations.
• Maintain accurate and timely documentation in the medical record and track referrals, patient contacts, and follow-up needs.
• Collect and enter data to support program reporting, quality improvement, and evaluation.
• Utilize clinical, research, and quality databases as appropriate.
• Work independently while maintaining strong communication and collaboration with the healthcare team.
• May conduct home visits as needed.

Required Qualifications

• 2-5 years of experience in a medical or healthcare setting.
• Experience working with diverse populations and individuals with complex medical and social needs.
• Strong organizational, communication, documentation, and computer skills.
• Ability to work independently and collaboratively as part of an interdisciplinary team.
• Strong patient advocacy and care coordination skills.

Preferred Qualifications

• Bilingual skills.
• Experience in care coordination, chronic disease management, or working with community resources.

Education

High School Diploma (Required)

Certifications

Driver License - OtherOtherOther

Compensation Note

The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum - Midpoint - Maximum $25.26 - $29.03 - $34.33

Equal Employment Opportunity Employer

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.

About Baystate Health

Baystate Health (BH) is one of New England’s leading and largest integrated health care organizations, serving a population of nearly one million people throughout western New England. With roots dating back to the founding of Springfield City Hospital in 1873, Baystate Health has been providing high-quality and compassionate health care in western Massachusetts for more than 145 years. With more than 12,000 employees, a medical staff of nearly 3,100 physicians, and a net patient service revenue of more than $1.4 billion, the ever-growing health system includes five Massachusetts hospitals and the Baystate Mary Lane Outpatient Center in Ware: Baystate Medical Center in Springfield Baystate Children's Hospital (located at Baystate Medical Center) Baystate Franklin Medical Center in Greenfield Baystate Wing Hospital in Palmer Baystate Noble Hospital in Westfield