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Care Coordinator Aco

Full/Part Time: Full Time
Location/Affiliates: The Mount Sinai Hospital
Department: 084 - Mount Sinai Care
Requisition Number: 14-1616828

Job Description:

The Care Coordinator for the ACO is responsible for coordinating care and providing guidance to primarily low-risk patients. Develops effective interpersonal relationships with patients and works collaboratively with the interdisciplinary care team to improve health outcomes. Utilizes internal and community resources, electronic medical record and Centers for Medicare and Medicaid data to educate patients and form a care plan with specific health outcomes.

Duties and Responsibilities:

1. Works to provide and improve continuity to the patient's experience before, during and following engagement within the health system. Interacts with patient and patient caregivers as appropriate to ensure continuity of care, patient adherence to care plans, and identifications of barriers preventing adherence to care plan.
2. Gathers information regarding the individual patient's needs by collaborating with members of the patient's care team to assist in developing a comprehensive care plan.
3. Monitors the patient's goals and improvements in patient's health outcomes with the care team.
4. Assists care team to close care gaps through Epic chronic disease and prevention disease management registries by communicating with the healthcare professionals and informing them of the client's progress and potential concerns.
5. Coordinates care with other members of the care team to overcome any identified financial or social barriers that inhibit patients' medical care.
6. Coaches patients, patient families, and/or authorized care givers on how to use existing skills and develop new ones to make lifestyle behavior changes that can positively affect patient's health. Engages them in the use of MyChart, to facilitate electronic access of patient's health care information.
7. Communicates with external vendors to facilitate adherence to the care plan, such as transport companies, childcare facilities, durable medical equipment companies, legal and housing services, etc.
8. Documents all patient encounters as appropriate in hospital documentation system and assists with the development of standardized reports on quality, utilization, processes and outcomes of the care coordination process.
9. Educates patients regarding how to navigate throughout the health system.
10. Performs other duties as required.

Job Qualifications:

Education:
Bachelor's degree required, preferably in a health related profession

Experience:
Some experience in healthcare or related field preferred. Bi-lingual candidates (English/Spanish) are highly desirable.

Ability to learn hospital ambulatory scheduling system, electronic medical record and new applications used for care coordination.

Must have excellent oral and written communication skills and ability to foster a supportive environment for patients.

Mount Sinai Medical Center is an equal opportunity/affirmative action employer. We recognize the power and importance of a diverse employee population and strongly encourage applicants with various experiences and backgrounds. Mount Sinai Medical Center--An EEO/AA-D/V Employer.

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