Post Acute Medical

Clinical Care Coordinator

• Manage an assigned panel of Medicare beneficiaries
• Serve as the operational link among patients residing in assisted living facilities, their families and caregivers, providers, facility staff, and the interdisciplinary clinical team
• Schedule and coordinate regular provider visits for assigned patients
• Conduct structured patient outreach and assessments by telephone and in assisted living communities
• Collect clinical, functional, and psychosocial information
• Provide patient and family/caregiver education and support related to diagnoses, treatment plans, services, and self-management
• Develop and maintain effective relationships with patients, families, caregivers, and facility staff
• Assist clinical team members with obtaining medical records, laboratory results, imaging reports, and other relevant patient information
• Identify and address changes in condition, care gaps, medication concerns, unmet social needs, barriers to care, and opportunities to reduce avoidable emergency department visits and hospitalizations
• Support implementation and follow-up of patient care plans and service needs
• Communicate and track identified actions through resolution or escalation
• Contribute patient and care coordination insights to weekly interdisciplinary team discussions
• Maintain accurate, timely, and complete documentation of assessments, interventions, patient responses, communications, and follow-up activities
• Participate in quality assessment and performance improvement initiatives
• Maintain patient confidentiality and comply with HIPAA and applicable requirements
• Perform other duties as assigned

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