Spartanburg Regional Healthcare System
Responsible for providing telephonic based education and care management for in-patient and out-patients with chronic diseases and their caregivers; assisting clients with resources and support needed to manage their disease process in such a way that decreases their risk for complications, emergency room visits and hospitalizations. Properly document patient interactions as part of the care team. Responsible for assisting with community services. Assists with quality improvement for the department. Take responsibility; keep commitments; complete tasks on time. Volunteer readily; take independent actions; ask for and offer help when needed.
Provide care coordination and coaching services to members identified as high risk while inpatient in order to reduce readmissions. Complete the documentation necessary in Epic to facilitate communications and billing for Transition Care Management (TCM) codes.
After discharge, provide care coordination and coaching services to members identified with two or more chronic diseases. Complete the documentation necessary in Epic to facilitate communications and meet the requirements for billing Chronic Care Management (CCM) codes.
Conduct telephonic outreach to members identified as needing an Annual Wellness Visit. Schedule the office visit with the primary care physician. Complete the required interview that complies with the Annual Wellness Visit requirements prior to the office visit in order for the visit to be as efficient as possible and to facilitate billing.
Build and maintain positive working relationships with the patients, providers, nurse case managers, agency representatives, supervisors and office staff, from diverse cultural and socio-economic backgrounds. Work to reduce cultural and socio-economic barriers between clients and institutions.
Work with team members to provide linkages for the various health and social needs of members.
Assist members to identify socio-economic issues that affect their overall health and develop health/social management plans and goals.
Identify gaps in care and assists members in utilizing community services, including scheduling appointments with social services agencies, (including transportation vendors), and assisting with completion of applications for eligible programs.
Assist with patient medication adherence by: instructing the member on current medication list, reviewing medications with member and assist in obtaining refills.
Teach disease self-management (i.e. nutrition, symptom tracking and reporting).
Responsible for recruitment, engagement, and retention of patients into the program with chronic diseases. Must achieve productivity standards.
Must have excellent communication and computer skills.
Interact with members by phone and/or face to face; may be required to meet member in various health care settings, such as; physician offices, hospital.
Properly handles member records to ensure compliance with patient health information applicable to the preservation, accuracy, and completeness of communication and/or retention of patient information, meeting all HIPAA regulations and the HITECH Act provisions as required by law.
Serves as a back up to other Senior Care Coordinators.
Must be willing to work outside normal business hours on occasion.
All other duties as assigned.
Education: High School Required, Preferred Associate/Bachelors
Experience: Prior experience working as a Medical Assistant and/or working in a medical setting interacting wipatients and clinical information.
Must maintain a valid US Drivers License and good driving record.
Certified Medical Assistant and/or Licensed Practical Nurse, or Assessment-Based Recognition in Order Entry (ABR-OE) Credential