- Full Time
- Posted 1 month ago
Website Associates in Family Medicine, P.C.
AFM’s Care Coordinators serve as the extension of our primary care providers both to our defined patients and the community. They will promote high-quality, appropriate outcomes, by assessing plans, coordinating with outside providers, the patient’s social structure, and the patient’s PCP, to monitor and evaluate the patient’s individual situation and services required to get them to their optimum health. Our Care Coordinators will also be a resource within our practice to educate and assist our clinical staff with day to day care coordination and access to other resources in our community.
Essential Job Duties and Responsibilities:
- Patient care management /coordination focusing on payer-based cost and risk data. Initial emphasis on CPCI patients and CPCI payer provided data. Estimated case load of 50-100 patients per FTE care manager initially.
- Care management focused on population-based data, rather than episodic, random care coordination.
- Provide some provider-driven or provider-initiated episodic patient care coordination and work with other AFM staff to most effectively assist patients with these services.
- Maintain close contact with the MACC team (Medicaid) regarding patients managed through that program and to avoid duplication of services. AFM may refer some very high needs patients to this resource for complex case management
- Patient care management may include inpatient visits, SNF visits, attending office visits, home visits, and family conferences and meetings.
- Involve the family and other social supports in developing and following the care plan.
- Assist patient and support persons (family) to set goals and make plans to assist the patients in reaching those goals.
- Assess patients’ barriers to health and their coping skills and through multiple models (including motivational interviewing) be able to improve those.
- Promote self-care and independence to the patients that they are working with.
- Continue the communications between hospital and PCP and Care Transitions team.
- Assist AFM staff with resources and provide appropriate staff education.
- Participate in CPCI monthly meetings, or regional collaborative learning events.