Outpatient Care Coordinator

In 2020 united in a fierce commitment to deliver the highest quality care and exceptional patient experience Virginia Mason and CHI Franciscan Health came together as natural partners to build a new health system centered around the patient: Virginia Mason Franciscan Health. Our combined system builds upon the scale and expertise of our nearly 300 sites of care including 11 hospitals and nearly 5000 physicians and providers. Together we are empowered to make an even greater impact on the health and well-being of our communities.

This job is responsible for working in concert with a provider/interdisciplinary team to assist in providing care coordination across the healthcare continuum in accordance with a plan of care that meets identified needs and incorporates services/resources that will facilitate improved outcomes and quality of daily life. An incumbent performs psychosocial and other screenings for review by the Registered Nurse Care Manager. They may provide information/guidance to the patient/family for effective care transition, improved self-management skills and to reinforce the need for active participation in maximizing overall health. Care transition is conducted primarily through telephonic communication and patient clinic visits. Work is focused on selected patient populations.

Work includes: 1) identifying the psychosocial needs of post-acute care patients, including completing psycho-social screening of the patient and evaluating the patient’s level of functioning; 2) assisting RN in coordinating and monitoring patient care between provider visits; 3) assisting patients in obtaining prescribed medications, making appointments for services, arranging for home medical equipment, completing various care-related forms and similar activities; 4) collecting, updating and communicating patient information which could impact the plan of care; and 5) identifying community and other resources and connecting patients with services that address needs and gaps in the healthcare continuum, improve outcomes and facilitate overall achievement of self-management goals.

An incumbent works collaboratively with the RN Care Manager, clinic physicians and other healthcare providers to provide care coordination across the healthcare continuum and to optimize access to community resources.
Work requires understanding of psychosocial and educational concepts, usual practices and accepted guidelines for patient care, community resources and applicable regulatory requirements. Knowledge of transitional case management concepts, methodologies and tools is also required. An incumbent uses the plan of care in giving patients the tools they need to assist them in taking charge of their medical/psychosocial conditions to improve their overall health and quality of life, and to decrease the potential for hospital admissions/readmissions.

• Bachelor’s degree in social work, psychology, geriatrics, or related field and one year of related work experience that would demonstrate attainment of the requisite job knowledge/abilities.
• Work experience in case management, social work or discharge planning is preferred.

Licensure/Certification: 

• Eligible for Agency Affiliated Counselor prior to date of hire and credential obtained within 60 days of hire, OR
• Current Licensed Social Workers Association Independent Clinical (LSWAIC).