Posted in Other 3 days ago.
Provides care coordination services to high risk individuals to improve the quality of care, mitigate cost trends, and improve patient and physician satisfaction. Utilizes evidence based guidelines to collaborate with physicians, patients and families to create a patient centered plan of care. Collaborates with the interdisciplinary team to promote a holistic approach to addressing clinical, psychosocial and financial barriers.
1. Utilizes risk stratification tools and pertinent clinical information to prioritize individuals in need of care coordination. Conducts comprehensive face to face and telephonic assessments of clinical, psychosocial and financial risks to develop a Plan of care, facilitate safe transitions and coordinate care across the care continuum.
2. Utilizes motivational interviewing techniques as part of the clinical assessment process to understand a patient's perception of their condition and Identify barriers negatively impacting their health outcomes. Collaborates with patient and family to address identified barriers. Works towards increasing individual's self-efficiency in managing their condition.
3. Coordinates care to include referral management between patient, provider, and specialist and associated facilities. Collaborates with health team to ensure care is rendered at the right time in the right setting.
4. Participates in quality improvement measurement, and data collection to include populations with clinical and financial risk. Identifies and works with individuals and providers to close gaps in care. Facilitates self management skills.