- Patient and family assessment is conducted per established guidelines.
- An individualized longitudinal plan of care is developed in collaboration with the interdisciplinary team, patient, and family, and community providers to maximize quality and cost-effective outcomes while incorporating patient and family goals, expectations, and preferences.
- Education is provided to the patient, family, and the interdisciplinary team regarding community resources and insurance benefits to support the most effective use of these resources to promote maximize and maintain independence.
- Advocacy is provided to meet the comprehensive needs of the patient and family and to promote quality cost effective outcomes.
- Assistance with income replacement, health insurance, transportation, and referrals to appropriate and available community resources is provided.
- Communication and coordination is actively promoted between members of the interdisciplinary team, the payer and the community to minimize fragmentation of services and to maximize outcomes; patient centered team meetings are planned and conducted when indicated.
- Assistance with problem-solving and availability as a resource to the outpatient clinicians is provided.
- Culturally competent care is displayed to identify the patient's cultural needs and incorporate them in the development of the longitudinal plan of care.
- Documentation is completed in adherence to department standards.
- Additional department, organization, or network activities are completed per established objectives.
- Bachelor's degree required; concentration in health or human services discipline.
- Masters degree from an accredited school
- Case management, utilization review, or discharge planning experience in an acute, rehabilitation, skilled nursing or outpatient setting is required.
- 5 years of related pediatric experience is preferred
- Current, unrestricted license to practice in Massachusetts in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline. Examples are Nursing, Physical Therapy, Occupational Therapy, Speech/Language Pathology, LCSW, Respiratory Therapist or Rehabilitation Counselor.
- LCSW, or LICSW
- Knowledge of community services and the healthcare systems required
- Knowledge of criteria and levels of care is required
- Access to reliable transportation to travel to pediatric outpatient sites across the Spaulding Network as necessary
- Computer proficiency required. Microsoft office applications preferred with ability to learn new software.
- Knowledge of community services and the healthcare system is required.
- Highly developed communications and interpersonal skills, working with diverse population.
- Work independently, be self-directed and contribute as a member of a team.
- Anticipates challenges and develops and implements strategies for addressing them.
- High level of service delivery. Demonstrate initiative with ability to prioritize work, meet deadlines and adapt to changing situations.
- Attention to detail
- Bilingual
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care coordinator - Boston, MA , USA, United States - Partners Healthcare System
Description
Summary
Work directly with pediatric patients (and their families) in the outpatient setting who are injured, ill, or newly diagnosed with a pediatric condition and who may experience altering changes in income, health insurance coverage, physical access to their home, specialized transportation, and caregiver assistance to maximize independent function in the community.
Collaborate across the continuum of care and with the interdisciplinary inpatient and outpatient rehabilitation teams, community providers, and community agencies to promote the highest level of independent function and an active, productive and fulfilling life.
Direct and assist patients and their families in the application process for federal, state, and private resources and provide access to specialized disability community resources.
Key ResponsibilitiesQualifications and Experience
Education/Degree
Required
Required
Licensure
Required
Skills (Specific learned activity gained through training (e.g. computer skills, keyboarding, presentation, CPR, ACLS, etc.)
Required
