Care Coordinator

Care Coordinator

Reporting to the Sr. Manager, Clinical Operations, a Care Coordinator works collaboratively with the care team to provide ongoing support and communication to Chronic Kidney Disease (CKD) and ESRD patients. The Care Coordinator acts as a single point-of-contact to coordinate resources along the care delivery spectrum, identify gaps, and provide proactive follow-up. The Care Coordinator is responsible for making sure the patient’s care at various locations is connected and there are no gaps in care or communication.

Essential Functions

• Performs outbound calls to patients to understand their clinical needs and connect them with appropriate resources
• Performs outbound calls to providers to make appointments for patients or follow up on care
• Answers inbound calls from patients, providers, and other resources
• Follows up with patients to ensure their needs are met and schedules future check-ins
• Coordinates with clinical resources and providers to ensure smooth continuum of care for patients.
• Monitors patient hospitalizations and follows up as necessary with care team members and outside resources to confirm Strive gathers all relevant patient information
• Notifies patients of location and appointment times as needed
• Ensures all patient records are up to date
• Provides patients with education materials and sends communications to primary care physicians, nephrologists, and specialists for new enrollments/appointments
• Assists with the referral process when needed
• Provides excellent customer service and treats patients
• Help patients and their families navigate the healthcare system and multitude of visits
• Fosters a relationship with patients across their healthcare journey with a foundation of respect, honesty, empathy, no judgement and follow-through 
• Skilled and passionate caring for patients with complex needs
• Collaborates well with all levels of a clinical team (from Medical Assistants to Physicians)
• Partners closely with the Strive NP to manage all pieces of care related to resources, appointments, care transitions, and care gaps
• Performs vital signs
• Meet in person with internal and/or external stakeholders to facilitate team and business priorities/opportunities. 
• Serve patients in person and in multiple care settings (e.g., patient home, clinics) in addition to virtual visits.   
• Home visits as determined by business need in market.
• Complete om person visits with members (in home or where convenient to patient).
• Serve as liaison between multiple service providers.
• Assist with enrollment in services and community resources.
• Assist with completing applications for resources, paperwork for provider visits, etc.
• Follow up on referrals for pharmacy, DME, home care, etc.
• Assist with finding and scheduling transportation.
• Deliver culturally competent care.

Minimum Qualifications

• High school diploma or equivalent required
• At least two (2) years of experience in a professional office environment
• Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms

Preferred Qualifications

• Customer service experience
• Active Community Health Worker Certification (CHW)
• Intermediate proficiency in MS Word, Excel, PowerPoint, and Outlook
• Excellent verbal and written communication skills
• Skilled at dealing with confidential information and/or issues using discretion and judgment
• Communicates clearly, respectfully, and thoughtfully