The Care Coordinator Scheduler as part of the Care Coordination department is responsible for creating a schedule for a group of Nurse Practitioners (NP) each day. The Care Coordinator Scheduler will arrange and coordinate the schedules on a daily and weekly basis, as well as route and organize patients in the order that the NP will see them in the home. They will ensure test results and records are requested and available for the appointment, and contact patients on a daily basis in order to arrange in advance and confirm next day appointments. Additionally, the Care Coordinator Scheduler would be responsible for tracking any patient currently admitted to a hospital or rehabilitation facility.
The Care Plan Coordinator works collaboratively with a qualified healthcare professional to plan, develop, modify, revise and implement Patient Centered Comprehensive Care Plans for all patients enrolled in the Chronic Care Management Program. Care Coordinators will work closely with patients, caregivers, and other healthcare professionals to ensure all information is documented accurately in the patient's comprehensive care plan. All time spent on this effort is documented in Aprima Care Management Tool. As members of the clinical staff, CPCs work under the direction and of a qualified health care professional to coordinate care for patients with multiple chronic medical conditions.
LHC Group is the preferred post-acute care partner for hospitals, physicians and families nationwide. From home health and hospice care to long-term acute care and community-based services, we deliver high-quality, cost-effective care that empowers patients to manage their health at home. Hospitals and health systems around the country have partnered with LHC Group to deliver patient-centered care in the home. More hospitals, physicians and families choose LHC Group, because we are united by a single, shared purpose: It's all about helping people.
Develop patient-centered care plan based on information documented in our EHR, Aprima, by the treating Provider. Review, revise and modify on a regular basis the care plan with the treating provider and patient or caregiver. The Care Plan Coordinator also reviews all documentation for accuracy and clarity and makes corrections as necessary to ensure appropriate treatment goals are clearly defined and communicated to the patient or caregiver and recorded in the care plan document.
Performs patient outreach in order to develop goals and advise recommendations based on chronic conditions, standards of treatment, and instructions developed by rendering provider.
Review patient's diagnoses (chronic conditions) and add treatment goals. These goals are assigned based on documentation in Aprima and will be discussed and confirmed with the Provider prior to sharing and explaining the care plan with the patient and/or caregiver.
Respond to patient and provider concerns, assessing urgency of need, and responding within the same business day. This includes determining if patient needs access to immediate care and establishing means for providing access to care with collaborative partners.
Frequent communication with Care Coordinators about which patients need outreach, establishment or updating of their care plan, or other chronic care management activities.
Assists the Care Coordinators with outreach to patients seen the day prior; updates care plans according to previous days' visits.
Obtains list from Care Coordinators daily on patients to either contact or who will need care plans updated based on previous days' visits.
Follow-up on previous days' patients, new and current, to perform outreach to patients if consent for CCM Services was not addressed at the visit.
Maintain an up-to-date electronic medical record of patient demographics, diagnosis history, medications and medication allergies for all patients enrolled in the Chronic Care Management Program to ensure accurate comprehensive care plans are produced.
Ensure patients and caregivers are aware of the 24/7 access to their Comprehensive Care Plan on the web-based Patient Portal, and can be provided with a written copy if requested.
Ensure distribution of patient-centered care plan to specialty offices, patient, and those involved in the patient's care to ensure coordination of care is completed, under the direction of a qualified healthcare professional. The care plan should be available via written copy, electronically, or verbally relayed to the patient.
Monitor delivery of care and status of patient by documenting patient, caregiver, or external healthcare professional's reports and disseminating information to the patient's primary care provider to update plan of care as needed.
Pursue missing orders as requested by patients, caregivers, and healthcare partners. If task requires additional orders be sent or specialized follow-up occur, notify Patient Care Coordinator of request via EMR message.
Follow-up on missing patient information at the request of the patient and/or caregiver via phone including, but not limited to: specialty referrals, lab results, imaging results, medical records, diagnostic testing, and other documentation required by provider at the follow-up visit with patient.
Monitor incoming e-mail, phone calls, and voicemails throughout day and respond within same business day regarding all matters pertaining to patient care and provider concerns.
Completes special projects as assigned.
Attends Company and industry-related meetings, as required.
Establishes individual goals which are aligned with the Company's business strategies and objectives.
Functions as a contributing member of the department's team and other teams, as assigned.
Performs other duties as assigned by executive leadership.
QualificationsCertified MA, LPN or other medically licensed professional.Proficient in Microsoft Office products.
LHC - Icims