Transitions of Care, Care Coordinator - IN (Indianapolis)
Cityblock
- Indianapolis, IN
- Permanent
- Full-time
- Aim for Understanding
- Be All In
- Bring Your Whole Self
- Lean Into Discomfort
- Put Members First
- Receive assignment of members from TOC team
- Reach out to member/caregiver to schedule post-discharge visit; describe the TOC program expectations and goals
- Complete assessments following protocols and as needed by the TOC Registered Nurse Care Manager (TOC RNCM)
- Support the TOC RNCM during discharge planning
- Partner with the TOC RNCM to develop post-discharge care plans that address identified needs and barriers to support a smooth recovery
- Support members in achieving their care plan goals
- Bring preliminary goals and identified resources to members to address social and care coordination needs
- Work with members to address goals in care plans and coach to completion
- Focus on members' goals, risk mitigation, call-us-first emphasis, provider engagement, and addressing social needs
- Participate in case conferences upon member discharge to discuss 30-day readmission mitigation plan
- Collaborate with TOC RNCM for hand-off to longitudinal care at conclusion of the TOC program
- Collaborate with TOC team to determine need for escalation of member care
- Weekly check-ins with members to follow-up on post-discharge care plan needs and progress
- Provide care coordination (e.g., benefits, social needs, external care) with the member/caregiver, internal care team and external providers
- Provide routine non-clinical education on preventative care topics
- Address and respond to member needs and delegate tasks in timely fashion
- Meet with members in the community (home, SNF, IRF, shelter, hospital) as needed, including as an extender of the care team for non-clinical needs
- Complete screenings for emerging needs
- Refers members to the TOC RNCM for clinical needs, while including other internal collaborators as necessary (e.g., pharmacy team, Behavioral Health Team, Mobile Integrated Care Team)
- Support loop closure on internal referrals
- Utilize our care facilitation, electronic health record and scheduling platforms as needed to collect data, document member interactions, organize information, track tasks, and communicate with your team, members, and community resources
- Track TOC metrics for assigned members and log new TOC events and accompanying follow-up metrics.
- HS Diploma
- At least 1-2 years of experience in community care or care coordination required
- Unrestricted Driver's License and vehicle for daily use
- Comfortable using technology to support members without in-person contact (telephone and text etiquette, virtual visit platforms, etc.)
- Understanding of how to use scheduling platforms to ensure accurate appointment scheduling and management
- Understanding of how to use electronic health record systems and/or care facilitation platforms to ensure accurate documentation
- Proficient in collecting member clinical and demographic data and documenting appropriately in a timely manner
- Versed in Motivational Interviewing and Trauma Informed Care principles
- Strong problem solving skills - can make difficult decisions and knows when to collaborate with other team members
- Able to provide creative solutions to challenges within the healthcare system that are impeding optimization of members' care and health
- Growth and learning mentality, ability to think outside the box, go outside the bounds of “traditional” responsibilities
- Adaptable to change and prepared for frequent, fast-paced changes and shifting priorities
- A resume and/or LinkedIn profile