Rn Care Manger / Care Coordinator
Finger Lakes Medical Associates
Rochester, New York Area
Care coordination between the physician's office and community agencies, ie: Home care agencies, agencies providing case management for long term medicaid waiver programs, coordination with hospital care managers/discharge coordinators for our patients in an acute care or short term rehab facility, Patient teaching for chronic diseases,early intervention to prevent rehospitalizations, and educating patients how to manage diseases in order to get the best quality of life possible. Assessing… Show more Care coordination between the physician's office and community agencies, ie: Home care agencies, agencies providing case management for long term medicaid waiver programs, coordination with hospital care managers/discharge coordinators for our patients in an acute care or short term rehab facility, Patient teaching for chronic diseases,early intervention to prevent rehospitalizations, and educating patients how to manage diseases in order to get the best quality of life possible. Assessing patient overall health intelligence and working with them at their level with motivational interview techniques. Ordering durable medical equipment for patients and assisting patients obtain needed medication. Also, worked phone triage for the internal medicine department. Assessing patient medical issues and determining the direction of care, i.e. office visit or send to ED. Often helping patients avoid ED visits for minor issues that could be handled in the office, or avoiding delay of care for emergent situations. Worked with administration, doctors and office staff to obtain a Patient Centered Medical Home Level 3 accreditation and then to maintain that accreditation. Show less