Care Coordination II Northwest

The Care Coordinator II will be responsible for helping individuals navigate and access community services and other resources that facilitate wellness and improve clinical outcomes via HCAM’s Access Health Program at Northwest Hospital.  Through an integrated approach to care management and community outreach, the Case Coordinator II supports the RN Medical Case Manager and Access Health Clinical Supervisor by acting as a patient advocate and liaison between the Access Health program and community service agencies to ensure that patients enrolled in the program have comprehensive and coordinated care. This support is also provided to the patient, and is achieved though consultation and interaction with hospital care management and discharge planning teams as well as local, state and community agencies.

The Care Coordinator II assists individuals in accessing health related services, including but not limited to obtaining a medical home, providing instruction on appropriate use of the medical home and overcoming barriers to obtaining needed medical care and social services.  Work is performed in hospital and community-based settings, (i.e., hospitals, provider offices) or in the client’s home and requires travel in the performance of patient engagement during non-traditional work hours.




Primary Responsibilities include:

  • Motivating Access Health patients to be active and engaged participants in their health;
  • Coordinates continuity of patient care through interdisciplinary collaboration and interagency coordination following hospital discharge and ED visits;
  • Facilitate Access Health patient access to appropriate medical and specialty providers
  • Educate patient and family/caregiver(s) about relevant community resources;
  • Provide referrals for services to community agencies, as appropriate;
  • Provide on-going follow-up, basic motivational interviewing and goal setting with Access Health patients and their families;
  • Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals
  • Work in collaboration with the clinical team (Social Workers, Registered Nurses, Physicians and Pharmacists) to support modifications to the personal health record/plan of care
  • Collaborate with internal HCAM resources and community agencies on case referrals, reporting, and supporting client needs associated with the Access Health program
  • Regularly evaluate the effectiveness of the plan of care based on the continuing documentation of the patient’s progress toward the established goals.
  • Complete home visits, as necessary, to assess the patient’s health needs and ongoing progress toward mutually established care plan goals
  • Participate in staff, community, professional and inter-agency meeting and conferences
  • Provide resources and education to Access Health patients and caregivers to maintain and support wellness


Required Qualifications

  • Current, active, unrestricted and non-probationary LBSW license required
  • Current BLS/CPR certification
  • A car and a valid driver’s license, with verifiable good driving record and reliable transportation
  • Knowledge of Maryland Medicaid and/or working with insurance companies. Completion of CAC certification is required within 6 months of employment.
  • Possess exceptional written and oral communication skills to interface with patients, other health care workers/providers and community, local and state agencies
  • Experience in chronic disease management, case management, utilization management and adult acute care is preferred
  • Proficiency in the usage of word processing, spreadsheets, email, internet, electronic patient medical data systems and web-based health information databases
  • Strong organizational skills and the ability to perform tasks independently
  • English proficiency in reading, writing and speaking to (1) interact with patient, (2) document the patients’ medical conditions in a standardized way, and (3) interact effectively with the staff at the hospital and other community agencies.
  • Other duties as assigned