The Patient Care Coordinator (PCC) supports designated Primary Care Teams, with an emphasis on chronic disease management and high-risk care coordination. As a co-located member of the Primary Care Team, the PCC oversees the registry of chronic disease patients and activates them to ensure adherence to care pathways. The PCC will be assigned respective duties to Chronic Disease Management or High-Risk Patients, and will work closely with Care Management and Social Work teams.
Primary Duties and Responsibilities
Supports patients in meeting their care goals and adhering to their pertinent care plan.
Conducts telephonic or electronic outreach to patients requiring follow-up on their care plan, in order to ensure continuity of proper care.
Engages patients in becoming active members in their care plan by utilizing motivational interviewing techniques.
Grooms provider schedules to ensure appropriate visit interventions.
Coordinates and attends patient case conferences with appropriate providers including the care manager and social worker; attends to any follow-up task emerging from case conferences.
Updates provider goals and care plans, if needed, to allow for visibility by entire care team.
Executes pharmacist orders to ensure adherence to pharmacist drug therapy plan, if the patient is enrolled in Drug Therapy Management (DTM).
Executes care coordination orders for patients as determined by provider, care manager, and social work; and maintains a daily management tracking system.
Schedules and confirms transportation, home health, DME, and other external vendors including community resources for patients.
Schedules pertinent provider appointments such as primary care, specialty, procedures, etc.
Ensures all discharge orders are completed per discharge plan or providers' order in accordance with their care plan.
Assists in verifying health plan benefits for any ordered services.
Remains available to assist with visit checkout for patients to ensure all needs are addressed prior to leaving clinic.
The PCC will be assigned to Chronic Disease Management or High-Risk Patients and will follow an escalation process to address non-adherence or any other patient concerns.
Establishes effective working relationships with cross-functional team(s)
Collaborates to problem solve and make decisions to achieve desired outcomes
Shares knowledge, time and expertise to assist other members of the team
Responds timely, effectively and appropriately to deliverables
Ensures practices and procedures are inclusive of interpersonal and cultural diversity
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical rese...arch and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.