Interacts with involved departments to negotiate and expedite scheduling and completion of tests, procedures, and consults.
Executes internal and external referrals to assure timely care for patients.
Provides targeted patient education.
Follows-up with patients after an emergency room visit or hospital discharge.
Handles non-appointment related calls from patients. Resolve the reason for the call or route to the appropriate party.
Provides an effective communication link between patient and medical staff, including relaying messages from providers, gathering information from patients for providers, etc.
Assists patients and providers in the medication refill process.
Ensures that all patients are tracked and data entered into systems for follow-up and reporting. Assists in coordination of care with pharmacies, insurance companies and other providers in the community and ensures that information goes when and where it is needed.
Participate in team decisions regarding data requirements for pro-actively managing the team’s panel.
Uses and updates the directory of resources in the service area to meet basic health and human needs. Be facile at using the resources available within the system.
Acts as a back-up to other Care Coordinators or to other Care Team members as needed.
Perform other job-related duties as assigned.