Description
The Care Coordinator is responsible for coordinating care and guidance to primarily at-risk patients from diagnosis to survivorship. Uses evidence based research to formulate the plan of care and ensure that patients at risk are following their protocols. Documents outcomes and maintains database of patient QI initiatives and outcomes. Coordinates the appropriate resources and consult services to provide continuity of care and appropriate follow up plan of care. Communicates with all members of the healthcare team. Initiates appropriate patient teaching based on needs. Supports the patient in decision making, may assist in coordination of end of life care if necessary. Develops effective interpersonal relationships with patients and works collaboratively with the interdisciplinary care team to improve health outcomes. Utilizes internal and community resources, electronic medical record and Centers for Medicare and Medicaid data to educate patients and form a care plan with specific health outcomes.

Responsibilities

• Provides guidance for patients from diagnosis to survivorship. Patients at risk are referred to the Care Coordinator to ensure that patient receives comprehensive and quality care with appropriate follow up.
• Initiates and documents patient interventions and referrals for data analysis. Uses evidence based research to assist in care plan and to provide external parties with information regarding patient data.
• May coordinate and assist patients to overcome any obstacles that may inhibit their care plan such as child care and transportation.
• Document all initiatives with patients in database so can quantify for both QI initiatives and internal documentation support.
• May work with Patient Navigators to ensure that benchmarks are met and reporting is completed in a thorough and timely fashion.
• May supervise a team of Patient Navigators via chart review, face-to-face case discussions and performance reviews.
• May work closely with MSH Security and New York City Police in any emergency situation where patient is not communicating or attending their treatment sessions.
• Initiates and documents patient teaching based on assessment of needs
• Partners with families and patient care team and community resources to provide well-coordinated timely compassionate, exemplary, interdisciplinary care.
• Initiates and performs ongoing review of policies related to services provided. Troubleshoots and updates as necessary.
• Serves as resource for community based education, screening, symposiums, educational sessions, lectures, staff training, etc.

Qualifications

• Bachelors degree in Health Sciences, Social Work or other professional degree.
• 1-3 years relevant experience in patient navigation preferred. Population specific experience very important. Excellent verbal and written communication skills to communicate effectively with patients, staff, visitors and vendors.
• Ability to speak Spanish desirable

• Provides guidance for patients from diagnosis to survivorship. Patients at risk are referred to the Care Coordinator to ensure that patient receives comprehensive and quality care with appropriate follow up.
• Initiates and documents patient interventions and referrals for data analysis. Uses evidence based research to assist in care plan and to provide external parties with information regarding patient data.
• May coordinate and assist patients to overcome any obstacles that may inhibit their care plan such as child care and transportation.
• Document all initiatives with patients in database so can quantify for both QI initiatives and internal documentation support.
• May work with Patient Navigators to ensure that benchmarks are met and reporting is completed in a thorough and timely fashion.
• May supervise a team of Patient Navigators via chart review, face-to-face case discussions and performance reviews.
• May work closely with MSH Security and New York City Police in any emergency situation where patient is not communicating or attending their treatment sessions.
• Initiates and documents patient teaching based on assessment of needs
• Partners with families and patient care team and community resources to provide well-coordinated timely compassionate, exemplary, interdisciplinary care.
• Initiates and performs ongoing review of policies related to services provided. Troubleshoots and updates as necessary.
• Serves as resource for community based education, screening, symposiums, educational sessions, lectures, staff training, etc