Position Summary:The Care Coordinator ensures patient navigation is implemented by managing client caseloads, coordinating primary and specialty care, overseeing transitions of care, and collaborating closely with patient schedulers for timely follow up appointments. Care Coordinators facilitate conversations between interdisciplinary care team members regarding transitions of care as well as patient family members post provider visits.Essential Duties and Responsibilities:The following duties and responsibilities generally reflect the expectations of this position but are not intended to be all inclusive, other duties may be assigned:Client Caseload ManagementAssist with delivering quality care for patients with chronic conditions by providing critical insights and valuable data to Eventus care teamsCalling patient family members/POAs/caregivers to provide update post provider visits with clinical updates, answer any clinical questionsProvide day-to day support and supervision of care - ensuring labs, specialty notes, hospital and SNF records are available in EHR for provider reviewReview patients' medical history and information from all available information sources including both internal care team and outside providers and servicesPerforms medication reconciliation after a transition of care and summary of SNF/hospital stayCreate Chronic Care Management (CCM) and Behavioral Health Integration (BHI) care plans in conjunction with the billing/rendering providers to include medications, diagnosis, patient goals and interventions, care team members, barriers, and patient education. Ensures that care plans are updated as necessaryEnsuring that the recommendations of the care plans are being adhered to and that proper treatment and therapies are being followed.Refers patients to needed services, such as specialist referralsCalls patients/POAs/caregivers within 48 hours after a discharge from a hospital or SNF to check in and schedule a follow up visitOrganizational and Administrative DutiesFacilitate discussions with health care providers to discuss client Care Plans, transitions of care, medication reconciliation, family input and specialty referralsDocument client services in patients chart, including updated history and medication reconciliation from their transition of care, summary of information discussed during phone calls, etc.Track client information and appointments in a confidential mannerInitiate outreach and missed appointment procedures, as necessaryAssist in disseminating tasks needed by providers to achieve quality metrics for value based care programs (I.e. depression screenings, BP readings and HGBA1C results)Assist with coordinating physician visits with scheduling for LTC ACO and follow up appointments within 1 week for ACO reach patients after a transition of careTrack time spent in care coordination activities to document for chronic care management minutesEnsure that all Medicare requirements of the CCM and BHI programs are being adhered to.Other duties as assigned.Education and/or Certifications:LPN degree or experienced certified MA with 5 years primary care experience2 years minimum experience in the LTC/ALF settingCare coordination experience preferredValue based care experience idealStrong understanding of cultural competency with the target populationCompetency with Excel, PCC, Matrix and Microsoft products with the ability to become proficient with company specific programs and software.Interest in working with geriatric clientsSkills and Qualifications:Commitment to the mission of care coordinationExcellent communication and interpersonal skills with ability to speak concisely to clients, patient schedulers, families and other interdisciplinary care team membersStrong knowledge of geriatric population and patient navigationOrganized with confidential client material, appointment tracking, and caseloadsDesire to build relationships with patients, family members and other members of the health care teamStrong organizational and time management skills, and ability to prioritize tasks and meet deadlinesProfessional verbal and written communication skills via phone, email, and other written correspondenceFriendly and professional demeanor.Physical Requirements: The physical demands described here are representative of those that must be met by an employee to successfully perform the job.While performing the duties of this job, the employee is regularly required to communicate with others, including the ability to express oneself and exchange information in what, at times, could be a stressful or high-pressure environment.The employee frequently is required to move about the office to access files, use office equipment, and to interact with others.The person must be able to sit or remain in a stationary position for extended periods of time to be able to work, communicate on the phone, utilize the computer, and interact with others.About Eventus WholeHealth: Eventus WholeHealth was founded in 2014 to provide physician-led healthcare services for residents and patients of skilled nursing and assisted living facilities. With our highly-trained team of physicians, psychiatrists, nurse practitioners, physician assistants, psychotherapists, podiatrists, optometrists, audiologists, and support staff, our comprehensive, evidence-based model provides collaborative interdisciplinary care with the seamless and vital integration of a wide range of specialties.Our differentiated approach not only empowers the facilities to reach their own goals and objectives but also ensures better patient outcomes. For more information, please visit