JOB SUMMARY: This role coordinates care of the Care Transformation Organization (CTO) assigned Medicare patients within the primary care provider's office. Works with an interdisciplinary team to manage care and coordinate care services attributed to partisan practices. Assess psychosocial needs and functional deficits of the patient and informs providers of changes in the care plan and/or patient's condition. Through an integrated approach, this role completes intake assessments, assists with the treatment planning, monitors patient progress, facilitates patient and family meetings, and coordinating and implementing of treatment referrals. This position plans and organizes community-based services that support the patients' self-management, adherence to treatment plans, and reduction of unnecessary re-hospitalization.

Care coordination:

* Assess psychosocial needs and functional deficits of patients

* Provide telephonic guidance, advice and support to patients

* Set health improvement / health management goals for patients

* Facilitate and coordinate care from within and outside of the practice

* Develop and maintain electronic care plan

2. Communicate with patients' primary care provider (physician or nurse

practitioner) regarding changes in patient status and/or care plan.

3. Utilize electronic medical record to document in an accurate, thorough, and

timely fashion.

4. Participate in team-based care. Willingly accept direction from providers and

serve as a clinical resource to medical assistants and other practice team

members. Communicate proactively.

5. Provide clinical coverage in the practice, as needed. Availability for practice

patients with acute care needs (especially if providers are not immediately

accessible).

6. Participate in educational programs and inservices supporting quality

improvement and clinical efficiency initiatives.

7. Serve as a resource for patients requiring special assistance (i.e. post-discharge

medication reconciliation) and/or short-term follow-up care (i.e. blood pressure

checks).

8. Leads by example; maintains high personal standards for customer satisfaction,

productivity, learning, cooperation, responsiveness; and optimism.

9. Establish an effective and appropriate means of communicating and collaborating

with providers, team members, payers and ancillary services to ensure safe and

efficient services.

10. Demonstrates professionalism; competence; and open communication style; high

integrity; energy, creativity, diplomacy; and flexibility.

11. Assists with other duties and special projects, as assigned.