Care Coordination Specialist
4 days ago
About the Role:
We are seeking a skilled Care Coordination Specialist to join our team. In this role, you will be responsible for coordinating care between hospitals and community care teams, ensuring seamless transitions for clients.
Main Responsibilities:
- Act as the primary point of contact for hospital navigators/coordinators.
- Receive, monitor, and update client tracking/notification/flow tools.
- Receive, review, and accept referrals for in-home transition services.
- Coordinate with hospital navigators/coordinators and SE @home Team as required.
- Participate in hospital discharge care conferences for complex clients as required.
- Prepare initial care plans and place equipment and supply orders as needed.
- E nsure all necessary referral documents and initial care plan instructions are received by SE @Home Team.
- Attend program huddles with hospitals as per contract requirements.
- Monitor and communicate significant deviations from care plans to hospitals as required.
- Communicate risk-related events to hospitals.
- Monitor timely completion and reporting outcomes of patient/family care conferences to partner hospitals (required in contract).
- Monitor Program Metrics (e.g., client experience, time to first visit, service volumes, risk events, etc.).
- Facilitate risk management according to established policies and procedures.
- Communicate patient and family complaints or issues back to partner hospitals and share associated action plans in partner meetings.
- Participate in program evaluation and process improvement.
- Be on-call as required for program support.
- Perform other duties to ensure program smooth operation.
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