Care Coordinator (Care Manager), Community Care Coordination Unit

Care Coordinator (Care Manager), Community Care Coordination Unit

Job Description:

The Care Manager supports and works within the Hospital, collaborating with patients' care teams, community service providers, government agencies, and multi-disciplinary hospital and healthcare teams to provide coordination and continuity of patient care across the healthcare continuum. This role supports patients and their family members in navigating their healthcare journey with the Hospital within the community.

Job Responsibilities:

• Assess and identify potential care gaps or red flags that inhibit smooth transition from hospital to home and community.
• Triage and assess patients' medical-nursing, psycho-social, functional status, and daily activity needs, as well as their existing support system availability upon enrollment into the program.
• Synthesize assessment information to prioritize care needs and develop care plans and goals together with patients and/or family/caregivers, in discussion with the patients' care team and community partners involved (if any).
• Initiate conversations with patients to understand their available social care support system in order to identify potential care gaps post-discharge/post-clinic consultation.
• Trigger earlier interventions and suggest suitable referrals to transitional care and community support services to support patients in the community and at home.
• Work in partnership with patients and families/caregivers on the various ranges of services and available options in the patients' community. Coordinate and follow up on referral outcomes accordingly and in a timely manner.
• Adopt a multi-disciplinary approach with a focus on coordination support. Make connections with transitional partners to facilitate support and assistance for individuals to address social and health issues.
• Conduct follow-ups via phone calls and/or home visits to ensure smooth coping of patients and caregivers.
• Promote and guide positive changes in patients' lifestyles in the community.
• Monitor patients' general medical conditions during home visits and report to patients' Principal Physician or primary care provider and/or community partner where necessary.
• Educate and promote advanced care planning, assisting patients and their families/caregivers in planning for and improving end-of-life care, ensuring that choices are reflected in personalized care plans.
• Document assessments, plans, and outcomes promptly and accurately in the relevant system.
• Maintain high-level contact with step-down facilities.
• Advocate for patients and their families/caregivers; form strong relationships with community partners to work in the patients' best interests.
• Participate in activities that contribute towards the improvement of patient care, including professional development sessions to develop relevant areas of knowledge, skills, and attitudes.
• Participate in projects and/or community events organized by Alexandra Hospital or partners within the community.
• Any other duties as assigned by the Reporting Officer.

Requirements:

• Degree or equivalent professional qualifications in Nursing, Social Work, or Allied Health profession.
• 3-5 years of experience in healthcare settings is preferred.
• Knowledge in geriatric and community care will be an advantage.
• Strong team player, with a natural ability to interact with healthcare staff and community partners of all levels.
• Organized, analytical, able to fit different pieces of the puzzle together.
• Pleasant disposition, approachable, with strong interpersonal and relational skills.
• Good verbal and written communication skills.
• Ability to use local languages and dialects will be an advantage, especially coupled with experience interacting with and managing patients and caregivers.
• Independent worker, with strong initiative.
• Comfortable with ambiguity, unchartered territory, enjoys challenges and problem-solving.
• Enjoys continuous improvements and embraces changes to actualize new initiatives.
• Equipped with basic computer skills in MS Word, Excel, and PowerPoint.
• 5 days work week.

Job ID: LRW5386X

All successful candidates can expect a very competitive remuneration package and a comprehensive range of benefits.

Kindly email your resume in a detailed Word format to gesse.tan@peopleprofilers.com

We regret that only shortlisted candidates will be notified.

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