Care Coordinator

JOB SUMMARY: The Care Coordinator is a Social Worker who facilitates patient continuity of care with the healthcare team. Under the clinical direction and oversight of the Primary Care Physician, the Care Coordinator coordinates care for high risk/complex patients by collaborating with the patient, family, physician, nurses, and other members of the healthcare team to identify needs and expedite appropriate, cost effective care. The Social Worker partners with the RN Care Coordinator to facilitate the care models of DVACO by coordinating services and community resources and meeting member socioeconomic needs to support the quality of life. S/he assists in the development of the patient’s care plan and collaborates with the Primary Care Physician to provide leadership in issues of outcomes management, disease management and prevention, and development of improved strategies to benefit high risk patients. The Care Coordinator may serve as the patient’s primary conduit to the primary care provider as they help coordinate necessary services both within and outside the practice, coordinating care from a variety of sources – physicians, specialists, home care providers, rehab centers, pharmacists, etc. They will engage patients and encourage them to take an active role in their health by providing them with the tools necessary to make healthy lifestyle choices and adopt life-long healthy behaviors. The social worker will serve as an advisor to the clinical team for health and human services resources as well as guardianship and behavioral health issues. ESSENTIAL ACCOUNTABILITY: Patient and Family Empowers and engages patients and families to represent themselves and advocates the patient’s perspective. Recognizes the holistic interrelationship that exists within and across the health system and...