Patient Care Coordinator

WellBe Care Model

The WellBe care model is a physician led advanced geriatric care program focused on the quality of care of the frail, poly-chronic, and elderly Medicare Advantage patients. This population is typically underserved and very challenged with access to overall health care. To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care. WellBe's Care Model is to provide our members the entire continuum of care from chronic to urgent care in the home, hospital, skilled nursing facility, assisted living, palliative care, and to end of life care. WellBe's physician / advanced practicing clinician led geriatric care teams partner with the patient's primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.

Job Description

Our Patient Care Coordinator are part of a home-based care team that provides compassionate care to the frail population who suffer from chronic and acute illnesses or injuries. Our PCA's are responsible for answering incoming and outgoing calls, coordinating care with the rest of the medical team, scheduling patient appointments, specialist appointments and coordinating diagnostic tests, being a community resource, working to engage patients that currently are not engaged, and contributing complete and accurate data in patient's records. The successful candidate will employ critical thinking and decision making, be comfortable with technology, have flexibility, and love working with patients and a collaborative interdisciplinary team. We offer a positive, upbeat work environment where all medical personnel work together for the good of the patient.

Skills & Competencies

Practices the WellBe mission : To help our patients lead healthier, meaningful lives by delivering the most Complete Care.

Updates and maintains all digital client records and assist in transitioning hard copy records to digital format

Acts as a community resource for the patient

Conduct patient scheduling, registration and eligibility verification

Manage patient medical records as appropriate

Answer phone calls and emails from patients, make outcoming calls, prioritize patient concerns as appropriate

Answer patient non-clinical questions and explains the process

Schedules / coordinates WellBe provider visits with patients, tests, specialist appoints, social resources

Ensures all appropriate patient information is in the EMR

Provide positive customer service and treat all patients and staff with respect

Prioritizes urgent patient needs, scheduling needs for Complete Care Assessment, and efforts to engage the unengaged

Collaborates with the interdisciplinary team and participate in regularly scheduled team meetings

Support APC in ongoing panel management and quality of care efforts (e.g., HEDIS)

Completes next day visit chart prep

Utilize reporting to help providers track, meet and exceed team goal

Other tasks needed to accomplish team's objectives / goals

Job Requirements

Educational / Experience Requirements :

• High school graduate or GED

License, Certification, Registration :

Required Skills and Abilities :

Supervisory Responsibility : N / A

Travel requirements : No travel is required

Work Conditions : Ability to lift up to 20lbs. Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assist with weights of more than 100lbs. Ability to stand for extended periods. Ability to drive to patient locations (ie. home, hospital, SNF, etc). Fine motor skills / Visual acuity

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification. Management reserves the right to add, modify, change or rescind the work assignments of this position. Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role.