Care Gaps Coordinator

Job Responsibilities

• Provides patient outreach for QI measures and gaps in care, including medication adherence, preventive visits, screenings, and chronic conditions
• Monitors hospital and ER admissions and discharges daily via Meditech, DRVS, and other sources
• Documents care coordination tasks within the EMR
• Documents all admissions and discharges on the Transitions of Care tracking spreadsheet and assigns a Case Manager to follow up
• Contacts patients to schedule follow-up appointments according to the discharge instructions
• Tracks patients’ progress through the transition of care process up to and including keeping follow-up appointments
• Reviews medical records to ensure data is complete and pending labs/tests are sent when available
• Requests and tracks hospital/ER records from other facilities
• Audits schedule for ER/hospital follow up appointments and ensures records are given to the PCP prior to the visit
• Collaborates with the care team, shares pertinent information, and alerts case managers or CHWs if their services would be appropriate
• Provides information and assistance to veterans on seeking and receiving benefits from VA Choice programs
• Completes appropriate paperwork for VA authorizations and all follow-up
• Completes authorizations for all VA referrals and follow-up
• Collaborates with providers/referral coordinator to ensure the necessary referrals are finalized
• Other duties as assigned