Care Coordinator - Primary Care

Job Details: Job Location: Fargo Headquarters - Fargo, ND, Position Type: Full Time, Education Level: High School, Salary Range: $18.57 - $27.86, Job Shift: Day, Job Category: Health Care, Our mission:   'To provide comfort and care through life's journey’ Join our team today!  Position Summary: The Care Coordinator (MA/CNA) supports HIA Health's Primary and Palliative Care programs by providing ongoing care coordination for medically complex, chronically ill, and high-risk patients. Responsibilities include chart preparation, patient outreach and follow-up, medication and care plan support, coordination of identified care needs, and other clinical and administrative activities that promote continuity of care and support the established plan of care. Chronic Care Management and Longitudinal Care Coordination  Provide proactive and responsive outreach to patients and caregivers to support continuity of care, ongoing needs, established care plans, preventive care, self-management, and access to appropriate services.  Coordinate care across Primary Care, Palliative Care, specialists, hospitals and clinics, residential facilities, pharmacies, home health agencies, DME suppliers, therapy providers, community resources, and other members of the care team.  Follow up on provider-directed care plans, patient needs, care gaps, referrals, tests, orders, equipment, services, and other care-coordination needs.  Support transitions of care following emergency department visits, hospitalizations, rehabilitation stays, or changes in care setting and facilitate appropriate follow-up with the care team.  Identify barriers, unmet needs, reported changes, or concerns and route or escalate matters requiring clinical assessment or judgment to the appropriate licensed nurse or provider.  Assist with identification and ongoing coordination of high-risk patients and support appropriate care-management workflows.  Document CCM and longitudinal care-coordination activities accurately, timely, and according to organizational requirements. Patient, Caregiver and Care Team Communication  Answer and respond to calls, messages, and other communications from patients, families/caregivers, facilities, providers, pharmacies, and healthcare professionals in a courteous and timely manner.  Promote timely access to appropriate care, patient education, self-management, shared decision-making, and continuity of care through collaboration with the patient and interdisciplinary care team.  Recognize time-sensitive or potentially urgent information and promptly route or escalate clinical concerns to the appropriate licensed nurse or provider.  Participate in interdisciplinary group (IDG), team, case-review, and organizational meetings as required; arrive prepared and provide needed handoff information before planned absences. Medication and Care Plan Support  Obtain current medication lists from patients, caregivers, facilities, pharmacies, discharge records, and other available sources and assist with medication-list reconciliation within authorized workflow.  Identify medication-list discrepancies, adherence barriers, reported medication concerns, or questions and route them to the appropriate licensed clinician or provider.  Follow up on provider-directed medication changes and routine refill requests as permitted by organizational policy and role authorization.  Reinforce provider- or care-team-directed instructions and support completion of established care-plan activities without independently changing the plan of care. Orders, Referrals and Service Coordination  Enter, transmit, track, and follow up on provider-directed orders according to organizational policy and role authorization.  Track and coordinate completion of laboratory testing, diagnostic testing, procedures, referrals, specialist appointments, and other ordered services.  Complete or assist with prior authorizations for medications, durable medical equipment (DME), procedures, and other services.  Initiate or assist with provider-directed DME, home health, home infusion, physical therapy, occupational therapy, and other services and follow through to completion.  Communicate unresolved barriers, delays, or incomplete services to the appropriate member of the care team. Chart Preparation, Records and Preventive Care Support  Prepare patient charts for Primary Care and Palliative Care provider visits and reconcile available information received from facilities, hospitals/clinics, health information exchanges, registries, and other sources.  Review and update available diagnoses, allergies, medication lists, immunizations, surgical/history information, and other chart elements as appropriate to role and workflow.  Verify immunization history using state registries and available records and follow established workflow for documentation and registry updates when authorized.  Support preventive care and care-gap follow-up, including Annual Wellness Visit preparation and assistance with Health Risk Assessment (HRA) completion when applicable.  Coordinate receipt of medical records and other information needed for continuity of care, care management, and provider review. Documentation and Care Management Workflow  Maintain complete, accurate, and current patient records in the electronic medical record.  Document patient, caregiver, facility, provider, and community-resource contacts and care-coordination activities accurately and concisely.  Complete documentation on the same day the contact, communication, or care-coordination activity occurs, consistent with organizational policy.  Maintain assigned follow-up tasks and care-management work queues so outstanding patient needs are tracked through completion, escalation, or handoff.  Follow organizational standards for CCM documentation, time capture, EMR workflows, and productivity expectations. Performance and Productivity Expectations CCM and longitudinal care coordination represent a significant portion of the Care Coordinator’s daily workload. The Care Coordinator is expected to maintain assigned patient work, complete timely outreach and follow-up, document work accurately, and meet established departmental productivity expectations. Detailed standards for CCM productivity, qualifying activities, documentation, time capture, and AdvancedMD workflows are maintained in separate departmental procedures and expectations documents. Benefits:We offer a robust benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, short-term and long-term disability, and a generous time off package.We have a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment. Expectations of all EmployeesSupport the mission, vision and values through unequaled quality patient care, professional competence, collaboration, communication, innovation, accountability, ownership and provide support to the entire agency regardless of their primary office location.HIA Health has HEARTHonor - Accepting the honor of service to hospice patients, families, and communities.Excellence - Striving for excellence in my work, as we stand on hallowed ground.Attitude - Choosing a positive attitude at work.Respect - Training people with the same respect I wish to be given.Teamwork - Valuing everyone’s contribution in delivery of care, operation of the organization and stewardship of our resources.Qualifications: Education, Certificates and Experience: Highschool Diploma or equivalent Certified Nursing Assistant (CNA) or Certified Medical Assistant (MA) 2+ years of experience in a healthcare setting (preferred) Familiarity with electronic medical records (EMRs) Strong clinical skills Strong interpersonal communication, organization and computer skills Familiarity with principles related to end of life Current certification in North Dakota and Minnesota Current driver’s license and auto insurance