Livingston, Montana
Health and Social Care Coordinator Job Opening in Livingston, Montana - Livingston HealthCare is accepting applications for a full-time Health and Social Care Coordinator.
Livingston HealthCare, in Livingston, Montana, is a not-for-profit, 25-bed critical access hospital with a Level 4 Community Trauma Facility, a multispecialty provider clinic, as well as rehabilitation, and home-based services. Livingston HealthCare is a member of the Billings Clinic system.
Livingston HealthCare was recently named one of the top 20 Critical Access Hospital in the U.S and just moved into a $43.5M state of the art facility.
JOB SUMMARY:
The Care Coordinator works in collaboration and continuous partnership with chronically ill or ?high-risk? patients and their family/caregiver(s), providers and staff, and community resources in a team approach to:
Promote timely access to appropriate care
Increase utilization of preventative care
Reduce emergency room utilization and hospital readmissions
Increase comprehension through culturally and linguistically appropriate education
Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s)
Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals
Increase patients? ability for self-management and shared decision-making
Provide medication reconciliation
Lead process changes to improve outpatient clinical quality metrics
Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs
ESSENTIAL FUNCTIONS, DUTIES, AND RESPONSIBILITIES:
Serve as the contact point, advocate, and informational resource for patients, care team, family/caregiver(s), payers, and community resources.
Work with patients to plan and monitor care.
Assess patient?s unmet health and social needs.
Develop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary, and ongoing action plan, as appropriate).
Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed.
Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination support they desire at any given point in time.
Facilitate patient access to appropriate medical and specialty providers.
Educate patient and family/caregiver(s) about relevant community resources.
Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed.
Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
Assist with the identification of ?high-risk? patients (the chronically ill and those with special health care needs), and add these to the patient registry (or flag in EHR).
Lead clinic chronic care management services consistent with Medicare guidelines.
Attend all Care Coordinator training courses/webinars and meetings.
Provide feedback for the improvement of the Care Coordination Program.
QUALIFICATIONS (Required):
Licensed and credentialed [Registered Nurse / Nurse Practitioner / Physician?s Assistant with prescribing privileges / Social Worker / Community Health Worker / Other].
3-5 years? experience in clinical or community resource settings; Care coordination and/or case management experience is desirable.
Job Type: Full-time
|
