Patient Coordinator Care Management

Responsibilities:

Connection

• Connects with patients on a regular basis to gauge completion of specific health interventions outlined in the Care Plan; such as, completion of appointments, medication compliance, use of community resources and other recommended follow[1]up activities.
• Responds to patient questions or concerns by telephonic or other methods of communication (MPM, etc.)
• Responsible for daily telephonic or electronic ED outreach using established guidelines and questionnaires.

Coordination

• Coordinates patient needs (e.g. social service, health and medication) in cooperation with the interdisciplinary providers including PCP, social work and pharmacists, payers.
• Interacts with patient service representatives or schedules follow-up for ED, hospital follow-up and acute care appointments.
• Monitors delivery of care through documentation and tracking of interventions in PennChart (specialty visit follow-up, labs, diagnostic studies, etc.).
• Coordinates completion of forms or scheduling for transportation and durable medical equipment based on practice specific needs.

Collaboration

• Evaluates outcomes of care with interdisciplinary care team during case reviews, providing the team with updates and progress of care plan for patients.
• Collaborates daily with the Care Manager to assist in meeting patient goals.
• Collaborates with the Community Health Worker regarding patient goals and concerns.
• Collaborates with the Social Worker or Pharmacist to follow-up on access to resources.
• Collaborates with the provider and medical assistants, as needed.

Documentation

• Documents in PennChart using the Care Management Navigator regarding coordination activities following established workflows and processes.
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures.
• Other duties as assigned to support the unit, department, entity, and health system organization.

Education or Equivalent Experience:

• H.S. Diploma/GED AND 3+ years relevant health care experience in a similar role REQUIRED.
• Associate's Degree with a focus in health-related or science area of study AND 1+ years of relevant health care experience in a similar role preferred.
• Bachelor's Degree with a focus in health-related or science area of study AND  0-1 years of relevant health care experience in a similar role preferred.