Eventus WholeHealth
Position Summary
The Care Coordination Team Lead ensures patient navigation is implemented by managing Care Coordinators and their client caseloads, training Care Coordinators in coordinating primary and specialty care, training Care Coordinators in transitions of care, and training Care Coordinators to collaborate closely with patient schedulers for timely follow up appointments. The Care Coordination Team lead also provides assistance to the Care Coordination Manager by assisting in training new hires, editing and approving time cards, filling in for team members when they are on PTO, and assisting with duties if the Director of Care Coordination is out on PTO.
Essential Duties And Responsibilities
Client Caseload Management (Small Caseload of their own and assisting with coverage for their team members out on PTO)
Assist with delivering quality care for patients with chronic conditions by providing critical insights and valuable data to Eventus care teams
Calling patient family members/POAs/caregivers to provide update post provider visits with clinical updates, answer any clinical questions
Provide day-to day support and supervision of care – ensuring labs, specialty notes, hospital and SNF records are available in EHR for provider review
Review patients’ medical history and information from all available information sources including both internal care team and outside providers and services
Performs medication reconciliation after a transition of care and summary of SNF/hospital stay
Create 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 necessary
Ensuring 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 referrals
Calls patients/POAs/caregivers within 48 hours after a discharge from a hospital or SNF to check in and schedule a follow up visit
Organizational and Administrative Duties
Facilitate discussions with health care providers to discuss client Care Plans, transitions of care, medication reconciliation, family input and specialty referrals
Document client services in patient 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 manner
Initiate outreach and missed appointment procedures, as necessary
Assist 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 care
Track time spent in care coordination activities to document for chronic care management minutes
Ensure that all Medicare requirements of the CCM and BHI programs are being adhered to.
Assist in leading assigned members of the care coordination team, by providing training, support, and leadership.
Training newly hired Care Coordinators on the Care Coordination workflow and systems.
Assisting the Director of Care Coordination by approving or editing timecards for other team members.
Filling in for the Director of Care Coordination when they are out on PTO.
Complete 5 audits per team member monthly.
Assist with referrals, medical records, and immediate needs for team members that are out on PTO.
Education And Certifications
LPN degree or experienced certified MA with 5 years primary care experience
1 year minimum experience with Eventus.
2 years minimum experience in the LTC/ALF setting
Care coordination experience preferred
Value based care experience ideal
Strong understanding of cultural competency with the target population
Competency with Excel, PCC, Matrix and Microsoft products with the ability to become proficient with company specific programs and software.
Interest in working with geriatric clients
Skills And Qualifications
Commitment to the mission of care coordination
Excellent communication and interpersonal skills with ability to speak concisely to clients, patient schedulers, families and other interdisciplinary care team members
Strong knowledge of geriatric population and patient navigation
Organized with confidential client material, appointment tracking, and caseloads
Desire to build relationships with patients, family members and other members of the health care team
Strong organizational and time management skills, and ability to prioritize tasks and meet deadlines
Professional verbal and written communication skills via phone, email, and other written correspondence
Friendly and professional demeanor.
Compliance Requirements
Adherence to Laws, Rules, Regulations, Standards, Guidelines, and Eventus WholeHealth Policies and Procedures.
Ensure compliance with all federal, state, and local laws, regulations, standards, guidelines, and Eventus WholeHealth policies and procedures pertaining to the job.
Remain informed of any changes to federal, state, and local laws, regulations, standards, guidelines, and Eventus WholeHealth policies and procedures that impact the job and the company.
Promptly report any non-compliant conduct and/or practices to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Ethical Conduct: Ensure adherence to Eventus WholeHealth's Code of Ethics and Business Conduct.
Perform the job duties with integrity and professionalism.
Promptly report any unethical conduct and/or practices to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Patient Privacy and Confidentiality: Strictly protect patient information in accordance with all federal and state privacy laws and Eventus WholeHealth policies and procedures.
Promptly report any violations of federal and state privacy laws and Eventus WholeHealth policies and procedures to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Documentation and Record Keeping: Maintain accurate and complete documentation when performing the job duties.
Ensure that all Eventus WholeHealth information, data, documentation, and records are always safeguarded and maintained confidentially.
Training and Education: Participate in all assigned training.
Complete all assigned training by the deadline for completion.
Risk Management and Incident Reporting: Engage in regular risk assessments to identify potential risks and work proactively with a supervisor and Eventus WholeHealth’s Chief Compliance and Risk Officer to mitigate any identified risks.
Promptly report any incidents (as defined in the “Incident Report Policy”) to the Chief Compliance and Risk Officer.
Physical Requirements
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 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. The employee is occasionally required to stand or otherwise be able to access files, equipment, and other items in high places.
Employee must be able to constantly operate computers, phones, and other office
Employee must be able to bend, stoop, kneel, crouch, or
Work Environment
The noise level in the work environment is usually low to
Due to the collaborative nature of the business and the need to service customers, the employee must be able to interact effectively with others in an office environment, manage conflict, and handle stressful situations and
Requires desk work in office
Ability to work flexible hours as needed to meet
Consistent with applicable federal and state laws, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. #J-18808-Ljbffr
Essential Duties And Responsibilities
Client Caseload Management (Small Caseload of their own and assisting with coverage for their team members out on PTO)
Assist with delivering quality care for patients with chronic conditions by providing critical insights and valuable data to Eventus care teams
Calling patient family members/POAs/caregivers to provide update post provider visits with clinical updates, answer any clinical questions
Provide day-to day support and supervision of care – ensuring labs, specialty notes, hospital and SNF records are available in EHR for provider review
Review patients’ medical history and information from all available information sources including both internal care team and outside providers and services
Performs medication reconciliation after a transition of care and summary of SNF/hospital stay
Create 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 necessary
Ensuring 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 referrals
Calls patients/POAs/caregivers within 48 hours after a discharge from a hospital or SNF to check in and schedule a follow up visit
Organizational and Administrative Duties
Facilitate discussions with health care providers to discuss client Care Plans, transitions of care, medication reconciliation, family input and specialty referrals
Document client services in patient 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 manner
Initiate outreach and missed appointment procedures, as necessary
Assist 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 care
Track time spent in care coordination activities to document for chronic care management minutes
Ensure that all Medicare requirements of the CCM and BHI programs are being adhered to.
Assist in leading assigned members of the care coordination team, by providing training, support, and leadership.
Training newly hired Care Coordinators on the Care Coordination workflow and systems.
Assisting the Director of Care Coordination by approving or editing timecards for other team members.
Filling in for the Director of Care Coordination when they are out on PTO.
Complete 5 audits per team member monthly.
Assist with referrals, medical records, and immediate needs for team members that are out on PTO.
Education And Certifications
LPN degree or experienced certified MA with 5 years primary care experience
1 year minimum experience with Eventus.
2 years minimum experience in the LTC/ALF setting
Care coordination experience preferred
Value based care experience ideal
Strong understanding of cultural competency with the target population
Competency with Excel, PCC, Matrix and Microsoft products with the ability to become proficient with company specific programs and software.
Interest in working with geriatric clients
Skills And Qualifications
Commitment to the mission of care coordination
Excellent communication and interpersonal skills with ability to speak concisely to clients, patient schedulers, families and other interdisciplinary care team members
Strong knowledge of geriatric population and patient navigation
Organized with confidential client material, appointment tracking, and caseloads
Desire to build relationships with patients, family members and other members of the health care team
Strong organizational and time management skills, and ability to prioritize tasks and meet deadlines
Professional verbal and written communication skills via phone, email, and other written correspondence
Friendly and professional demeanor.
Compliance Requirements
Adherence to Laws, Rules, Regulations, Standards, Guidelines, and Eventus WholeHealth Policies and Procedures.
Ensure compliance with all federal, state, and local laws, regulations, standards, guidelines, and Eventus WholeHealth policies and procedures pertaining to the job.
Remain informed of any changes to federal, state, and local laws, regulations, standards, guidelines, and Eventus WholeHealth policies and procedures that impact the job and the company.
Promptly report any non-compliant conduct and/or practices to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Ethical Conduct: Ensure adherence to Eventus WholeHealth's Code of Ethics and Business Conduct.
Perform the job duties with integrity and professionalism.
Promptly report any unethical conduct and/or practices to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Patient Privacy and Confidentiality: Strictly protect patient information in accordance with all federal and state privacy laws and Eventus WholeHealth policies and procedures.
Promptly report any violations of federal and state privacy laws and Eventus WholeHealth policies and procedures to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Documentation and Record Keeping: Maintain accurate and complete documentation when performing the job duties.
Ensure that all Eventus WholeHealth information, data, documentation, and records are always safeguarded and maintained confidentially.
Training and Education: Participate in all assigned training.
Complete all assigned training by the deadline for completion.
Risk Management and Incident Reporting: Engage in regular risk assessments to identify potential risks and work proactively with a supervisor and Eventus WholeHealth’s Chief Compliance and Risk Officer to mitigate any identified risks.
Promptly report any incidents (as defined in the “Incident Report Policy”) to the Chief Compliance and Risk Officer.
Physical Requirements
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 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. The employee is occasionally required to stand or otherwise be able to access files, equipment, and other items in high places.
Employee must be able to constantly operate computers, phones, and other office
Employee must be able to bend, stoop, kneel, crouch, or
Work Environment
The noise level in the work environment is usually low to
Due to the collaborative nature of the business and the need to service customers, the employee must be able to interact effectively with others in an office environment, manage conflict, and handle stressful situations and
Requires desk work in office
Ability to work flexible hours as needed to meet
Consistent with applicable federal and state laws, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job. #J-18808-Ljbffr