Care Coordinator/ Manager - Office Hours

at  ENVIRODYNAMICS SOLUTIONS PTE LTD

The Care Manager supports and collaborates with patient’s care team, community service providers, government agencies, and multi-disciplinary hospital and healthcare teams to provide coordination and continuity of patient care across the healthcare continuum; to support patients and their family members in navigating their healthcare stakeholders.

Job Responsibilities*

• Attending to medical queries received via a 24/7 integrated telephone hotline that forms a network for triaging patients, and provides an avenue to caregivers and community partners .
• Ensures that the medical query is escalated to the appropriate medical provider and follows up with proper case closure
• Performs triaging for transitional care referrals and right sites care to other external providers when necessary
• Triage and assess patient’s medical-nursing, psycho-social, functional status and daily activity needs; as well as their existing support system availability upon enrolment into programme.
• Provide guidance and assistance to Care Manager Associates in escalation of complex medical calls or referrals triaging when needed.
• Implement appropriate care coordination and transitional case management; and evaluate the outcomes accordingly.
• Synthesize assessment information to prioritize care needs and develop care plan and goals together with patient and/ or family/caregiver; with discussion with patient’s care team as well as community partners involved( if any).
• Work in partnership with patients and families/caregivers on the various ranges of services and available options in the patient’s community. Coordinate and follow up referrals outcome accordingly and in a timely manner.
• Adopt a multi-disciplinary approach with focus on coordination support. Make connections with transitional partners to facilitate support and assistance for individual to address social and health issue
• Conduct follow-up via phone calls and/ or home visits to ensure smooth coping of patients and caregivers.
• Promote and guide positive changes in patient’s lifestyle in the community.
• Monitor patient’s general medical condition during home visit and report to patient’s Principal Physician or primary care provider and/or community partner where necessary.
• Educate and promote advanced care planning, assist patients and their families/caregivers in planning for and improving end of life care, ensuring that choices are reflected in personalized care plans.
• Document assessments, plans, and outcomes promptly and accurately in the relevant system.
• Maintain high level contact with step-down facilities.
• Advocate for patients and their families/caregivers; and form strong relationships with community partners in order to work in the patient’s best interests.
• Participate in activities that contribute towards the improvement of patient care, including professional development sessions to develop relevant areas of knowledge, skills and attitudes.
• Any other duties as assigned by Reporting Officer.

REQUIREMENTS*

• Degree or equivalent professional qualifications in Nursing, Social Work or Allied Health profession.
• 3 - 5 years of experience in healthcare settings is preferred.
• Knowledge in geriatric and community care will be an advantage.
• Strong team-player, with natural ability to interact with healthcare staff and community partners of all levels.
• Organised, analytical, able to fit different pieces of the puzzle together.
• Preferably with 3 years of Nursing/ Healthcare experience background
• With MS word/ Excel/ Powerpoint skillsOffice Hours

• Attending to medical queries received via a 24/7 integrated telephone hotline that forms a network for triaging patients, and provides an avenue to caregivers and community partners .
• Ensures that the medical query is escalated to the appropriate medical provider and follows up with proper case closure
• Performs triaging for transitional care referrals and right sites care to other external providers when necessary
• Triage and assess patient’s medical-nursing, psycho-social, functional status and daily activity needs; as well as their existing support system availability upon enrolment into programme.
• Provide guidance and assistance to Care Manager Associates in escalation of complex medical calls or referrals triaging when needed.
• Implement appropriate care coordination and transitional case management; and evaluate the outcomes accordingly.
• Synthesize assessment information to prioritize care needs and develop care plan and goals together with patient and/ or family/caregiver; with discussion with patient’s care team as well as community partners involved( if any).
• Work in partnership with patients and families/caregivers on the various ranges of services and available options in the patient’s community. Coordinate and follow up referrals outcome accordingly and in a timely manner.
• Adopt a multi-disciplinary approach with focus on coordination support. Make connections with transitional partners to facilitate support and assistance for individual to address social and health issue
• Conduct follow-up via phone calls and/ or home visits to ensure smooth coping of patients and caregivers.
• Promote and guide positive changes in patient’s lifestyle in the community.
• Monitor patient’s general medical condition during home visit and report to patient’s Principal Physician or primary care provider and/or community partner where necessary.
• Educate and promote advanced care planning, assist patients and their families/caregivers in planning for and improving end of life care, ensuring that choices are reflected in personalized care plans.
• Document assessments, plans, and outcomes promptly and accurately in the relevant system.
• Maintain high level contact with step-down facilities.
• Advocate for patients and their families/caregivers; and form strong relationships with community partners in order to work in the patient’s best interests.
• Participate in activities that contribute towards the improvement of patient care, including professional development sessions to develop relevant areas of knowledge, skills and attitudes.
• Any other duties as assigned by Reporting Officer