Care Coordinator

Responsibilities

• Provides access to a single point of contact for all questions or inquiries
• Conducts assessments with Enrollees and / or their caregiver
• Develops an Individualized Care Plan that is periodically reviewed and updated
• Provides disease self-management and coaching
• Conducts medication review, including reconciliation during transitions of care settings
• Provides periodic monitoring of health, functional, and mental status, along with pain and fall screening
• Ensures the provision of services in the least restrictive setting and transition support across and between specialties and care settings
• Connects Enrollees to services that promote community living and help to delay or avoid nursing facility placement
• Coordinates with social service agencies (e.g., local departments of health, social services, and community-based organizations) and the referral of Enrollees to state, local, and / or other community resources
• Collaborates with nursing facilities to promote the adoption of evidence-based interventions to reduce avoidable hospitalization, management of chronic conditions, medication optimization, fall and pressure ulcer prevention, and the coordination of services beyond the scope of the nursing facility benefit

Education & Experience :

Licensure :