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• Facilitates communication and coordination between all members of the care team.
• Assists all patients throughout the care model by acting as a patient advocate and navigator
• Connect with providers and patients regularly via a telehealth platform and receive regular updates on patient activity that include vital signs and assessments.
• Coordinate referrals and appropriate resources to assist patient and/or caregiver in continuation of care in the outpatient setting.
• Assists in the tracking and prioritization of high-risk patients and ensures patients have access to services appropriate to meet their needs.
• Maintains all required documentation on provider and patient interactions including visits, intake, interventions, patient issues, and any other elements of the patient's individual plan of care.
• Generates operational, clinical, and quality reports and presents market updates on a regular basis.
• Manages clinical and operational workflows.
• Provides prompt, courteous, excellent service to internal and external customers at all times.
• Interacts with the patient and the multidisciplinary team to evaluate and document measurable health care goals. Communicates to the appropriate providers any patient environmental barriers to the adherence of the Care Plan.
• Communicates discharge information to other clinical departments or members of the Care Team.
• Watches for trends and hurdles involved in health care system and incorporates solutions for system challenges, including patient, family and physician responses into an evolving process and model that increases quality and satisfaction with the care experience - patient or physician.
• Builds and maintains collaborative professional working relationships with physicians, Medical Directors, clinicians, and community at large to develop and implement a successful cross-continuum care management.
• Monitors the care that the patient receives and brings it to the attention of a provider
• Assists as needed in recruiting, client and community outreach and critical incident/incident/complaint management.

• BSN
• Certification: Care Coordination and Transition Management (C.C.C.T.M)
• Regional knowledge: Prefer knowledge of the geographical area of the assigned market

Skills & Abilities

• Ability to provide superior customer service; every decision needs to be made with the patient in mind. Patient safety is our number one priority.
• Strong attention to detail and ability to maintain written records and reports. Excellent verbal and written communication that is clear, well-organized, and demonstrates an understanding of audience needs.
• Exhibits exceptional interpersonal skills and proper judgment when dealing with provider partners, staff and patients.
• Ability to predict needs as best as possible and stay one step ahead of the patient's care.
• Pursues activities with focus and drive, defines work in terms of success, and can be counted on to complete goals. A positive outlook and a can-do attitude is a must.
• Enjoys working within teams; dependable in both productivity and attendance. Flexible and willing to share on-call after hours with other Recovery Care Coordinators is required.
• Ability to consistently communicate with teammates; open to opinions and feedback from team members and follows through on all commitments.

Amedisys is an equal opportunity employer. All qualified employees and applicants will receive consideration for employment without regard to race, color, religion, sex, age, pregnancy, marital status, national origin, citizenship status, disability, military status, sexual orientation, genetic predisposition or carrier status or any other legally protected characteristic.