Job Type:

Regular

Scheduled Hours:

40

Job Summary:

Job Profile Summary Reports to the Manager of Care Coordination, The SEP Care Management Referral Coordinator (CMRC) is responsible for telephonic and face-to-face care management interventions. Areas of responsibility include the Care Management Referral Line, Referral Queue, and the execution of the SEP Grant Funded Transportation Assistance program. The CMRC supports other members of Care Management as indicated, which can include but not limited to referral audits, Health Maintenance/Care Gap closure, and Social Drivers of Health interventions.

A Care Management Resource Coordinator is a member of the Care Management Team and works closely with the entire care team to provide optimal services to the patient. The CMRC will strive to be a highly accessible position that is responsible for creating a positive impression with patients, providers, and other associates encountered, both in person and on the phone. The CMRC is oftentimes the initial contact a patient has with the Care Management Team, thus requiring knowledge of Care Management, critical thinking, soft skills, Motivational Interviewing techniques, and organization. The Care Management Referral Coordinator utilizes critical thinking and professional judgment to support the care management referral process in order to facilitate and maintain improved health outcomes for the community.

Job Description:

Job Title: Care Management Referral Coordinator Tier I Job Code 11159

BENEFITS:

• Paid Time Off
• Medical, Dental, and Vision
• 403b with Match

EDUCATION:

Minimum: Bachelor’s degree in a related field, and/or Associate's degree with equivalent experience Preferred: Bachelor's degree in Human Services

YEARS OF EXPERIENCE:

Minimum: 2+ years of experience in a health-related or community resources field. Preferred: Care Management experience

LICENSES AND CERTIFICATIONS:

Minimum: Valid driver’s license, reliable transportation, current automobile insurance

OTHER REQUIRED SKILLS AND KNOWLEDGE:

Working knowledge of Excel, Windows and Outlook and the ability to learn other computer skills as needed.

DUTIES AND RESPONSIBILITIES:

Care Management Referrals

• Answer all incoming calls to the Care Management Referral Line and provide appropriate resolution.
• Review and evaluate other incoming Care Management referrals via chart review for incoming referrals and assign appropriately, using critical thinking and knowledge of healthcare system.
• Conduct initial evaluations and/or assessments to determine the appropriate team member to route referrals to.
• Proactively identify and create appropriate referrals.
• Communicate with family and other resources to best meet the needs of patients and family.
• Inform care plan team members of incoming referrals as indicated.
• Schedule, cancel, and reschedule appropriate appointments for the Care Management Team based on patient needs.
• Link individuals and families to needed community resources, coordinate services, and monitor progress.
• Educate patients with resources, timelines, and goals for improving accountability and collaboration.
• Collaborate with patient/family/healthcare providers/community supports to coordinate needed services.

SEP Grant Funded Transportation Assistance

• Follow SEP Grant Funded Transportation Assistance policy and procedures.
• Complete applicable SEP Grant Funded Transportation Assistance paperwork.
• Coordinate appropriate and cost-effective SEP Grant Funded Transportation Assistance.
• Document and track SEP Grant Funded Transportation Assistance in central locations for associates and colleagues to easily access.

General Role Responsibilities

• Manage a roster of patients as assigned by incoming referrals & warm hand offs.
• Gather all relevant information via chart and/or patient assessment, collaborate with the healthcare team, and implement plan for desired outcome.
• Educate, schedule, and coordinate Health Maintenance/care gap closure.
• Evaluate Social Drivers of Health barriers and follow appropriate workflows to meet, resolve, or coordinate resolution.
• Connect patients with community support services and place appropriate hand off to resources as indicated.
• Complete face-to-face visits with patients, as necessary. Face-to-face visits can be held in the PCP office or in a community setting.
• Communicate appropriate and applicable information in accordance with HIPPA guidelines.
• Coordinate with the patient, family, care team, etc. to establish a plan of care for Social Drivers of Health and/or SEP Grant Funded Transportation Assistance.
• Ensure accurate and timely completion of documentation and follow up.
• Maintain effective communication with other members of the patient’s care team and Care Management Department.
• Provide education on St. Elizabeth Physicians and community support services.
• Use a holistic and collaborative approach to consult with care managers, supervisors, health care team members, etc. to meet goals and objectives.
• Participates in multidisciplinary care collaboratives and patient reviews to ensure optimal outcomes.
• Foster an environment of collaboration, professionalism, patient/colleague safety, and quality care.
• Attend and actively participate in department meetings, huddles, and care collaboratives as scheduled.
• Function as a liaison between patient/family and all members of the healthcare team.
• Build rapport with patients/family and healthcare teams.
• Resolve issues or problems in an open and constructive manner.
• Honor the dignity of every individual in all interactions.
• Integrate knowledge, skill, and experience to continuously improve self and the quality of patient care.
• Assist with patients’ requests in a timely manner.
• Utilize critical thinking and organization standards to ensure best practice guidelines are followed.
• Remain flexible and manage time effectively and independently.
• Provide services and interventions while maintaining clear, professional boundaries.
• Network with community agencies to provide additional support to patients and their families.
• Perform other duties as assigned.

Employee Care:

Professional Growth and Development:

• Maintain skills and knowledge as appropriate to the Care Management Referral Coordinator role.
• Participate in Leadership Academy and other educational opportunities to support professional development.

Performance Improvement:

• Review and commit to continuous improvement utilizing the monthly Key Performance Indicators as well as other performance metrics established as needed.
• Value feedback as an opportunity to gain experience and grow the Care Management Referral Coordinator role.

FLSA Status:

Non-Exempt

Right Career. Right Here. If you have a passion for taking care of the community and are interested in Healthcare, you will take pride in the level of care we provide at St. Elizabeth. We take care of patients and each other.

St. Elizabeth Physicians is an equal opportunity employer and will not discriminate on the basis of race, color, sex, religion, national origin, ancestry, disability, age or any other characteristic that is protected by state or federal law.