Position Summary: The role of the ACO Clinical Case Coordinator is to coordinate the care of Franciscan Health Plan members (employees and dependents) with complex care needs by partnering with the assigned providers, patients and caregivers. The goal is to effectively manage the patients over the continuum of care to ensure that their medical and psychosocial needs (social determinants of health) are met; barriers are identified and addressed; and a comprehensive individualized care plan is developed to positively impact their quality of life and clinical outcomes. The ACO Clinical Case Coordinator also acts as an advocate for these patients; links them to other members of the care team to help the patients gain knowledge of their disease process; and identify community resources for continued growth toward a maximum level of independence.
Essential Duties and Responsibilities: •Interact with patients both telephonically and in person in order to serve the daily case management needs of patients. •Act as a comprehensive care coordinator for assigned patients, develop interventions, assess the patient’s need accordingly and facilitate communication amongst other providers caring for the patient. •Perform comprehensive assessments of physical, emotional, psychosocial, and environmental needs of the patient. •Develop collaborative partnership with providers caring for the patient through frequent telephonic and/or in person interactions with the provider and office staff. •Develop interventions and processes to assist the patients in meeting short and long term goals. • Coordinate patient visits with PCP and specialists as needed. •Identify and provide emergency crisis intervention when needed. •Is sensitive to different cultural, religious, economic, and social groups and how it affects the knowledge, delivery, and acceptance of healthcare services and provide appropriate interventions as indicated. •Coordinate episodic care to eliminate unnecessary costs and ensure optimal outcomes •Provide support for disease management of chronic conditions •This position will be responsible for coordinating the care of a select patient case load •Maintain accurate and timely documentation in the care management system.
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Continuing Christ's Ministry in Our Franciscan Tradition. Each day, throughout the halls of our hospitals, we embrace our Franciscan Tradition by walking in the footsteps of St. Francis, who left behind his worldly possessions to care for all of those in need.