Local Care Coordinator (LCC), with the support and guidance of the CareFirst Regional Care Director
(RCD), supports the implementation of the CareFirst Patient-Centered Medical
Home (PCMH) program by working with members who are attributed to a Primary Care
Physician as well as members seeing a specialist practitioner and/or who do not
have a Primary Care Physician (unattributed) who are benefit eligible and meet
the selection criteria for Care Coordination. The LCCs works with Primary Care
Physicians (PCPs), Specialty Care Providers and regional support teams.
The Local Care Coordinator will advocate, guide and intervene on behalf of their members to
ensure successful implementation of the Care Plan while providing Complex Case
Management through the duration of the Care Plan. The LCC acts as the primary
interface between the CareFirst program and individual primary care providers
(PCPs), Specialist and their patients (members).
Under the general supervision of a Regional Care Director the incumbents accountabilities may
include, but are not limited to, the following:
Develop and maintain strong working relationships with PCPs, Specialists and other clinicians to
integrate the PCMH program into their practices.
Serves as an extension of the PCP office for PCPs who participate in the PCMH Program as well as
Provide on-site consultation to PCP and Specialists offices and Care Coordination Team
providers related to implementation of the PCMH model including development and
documentation of Care Plans for individual members, inclusive of tracking
processes, member self-management support, implementation of clinical practice
guidelines and work process/patient flow improvements. Follow-up with parties as
Collaborate with PCPs, Members and Specialty Providers in the development, documentation and
implementation of Care Plans and delivery of coordinated services for members
identified through this CareFirst program.
Facilitates and monitors
the transition of care which involves moving the member from one healthcare
practitioner and setting to another as their healthcare needs change, utilizing
TCCI programs as appropriate to meet the members needs. Implements and
oversees the agreed upon plan of care in conjunction with TCCI partners and
reviews all cases. Coordinates member follow-up post discharge for applicable
Maintain the electronic Care Plan.
Utilize established documentation standards to maintain quality of Care Plan documentation to
include member progress toward their established state of being and barriers to
achievement of Care Plan objectives/outcomes.
Develop communication and referral mechanisms to assure that there is seamless communication between
PCMH, PCPs, Specialists and the Care Coordination Team.
Abides by PCMH Program Description and Guidelines.
In conjunction with Regional Care Directors and PCMH Practice Consultants, develops clinical
reports for use in PCP office, facilitating PCP support of members in behavior
Assist the member in coordination of any additional tests, images and consults with specialists as
deemed appropriate by the PCP or Specialist. For selected members with multiple
prescriptions, perform a comprehensive medication reconciliation (CMR) at the
onset of the Care Plan, as well as every thirty days during the life of the
Care Plan, or when any medication is changed, added or deleted, assessing for
efficacy and drug interaction/side effects.
Identifies appropriate TCCI program partners and other healthcare providers/vendors as well as
Community Resources. Refers and follows-up on referrals and results.
Assesses the members ongoing care needs and progress towards goals throughout the case duration and
makes revisions as needed to address changes in the members condition, lack of
response to the care plan, preference changes, and transitions in care
settings. Coordinates plan of care with the provider with goals of member
stabilization, decreased admissions and medication management.
Direct the PCP or specialist practitioner to the Program Consultant or RCD when he/she identifies
an opportunity for education or additional learning needs surrounding the
Program that are outside of his/her understanding.
Coordinate patient education in support of standards of care guidelines and related health issues
using the most appropriate modality for the member.
Facilitate the completion of member satisfaction surveys, Patient Activation Measures (PAM)
and Post-PAM graduation.
Verbally or physically connect with each member every week.
Maintain member encounter rates and provides effective coordination of care
Completes mandatory training
Actively participates in team huddles and contributes to the clinical learning
Keeps current on clinical knowledge via self-directed learning
Effectively escalates issues and/or system issues to supervisor
Other duties as assigned
Local Care Coordinators are the face of CareFirst in provider offices, interacting directly with
CareFirst members face to face and telephonically. Like other RNs providing
care coordination, LCCs must be fully versed in all aspects of PCMH and TCCI in
order incorporate the TCCI elements into effective and successful Care Coordination.
Healthcare background and current licensure as an RN is required. BSN preferred.
Minimum 3 years clinical RN experience working with patients who have chronic illnesses (acute care,
home health, hospice, long-term care, or in a physician office setting).
Demonstrates computer competencies to include word processing, spreadsheet, presentation preparation,
and data base management. Demonstrated ability to learn customized computer
Maximize all technology inclusive of iCentric, Skype, Microsoft Word, Microsoft Excel, Microsoft
Outlook, laptop computers, iPhone, and all other relevant CareFirst unified
Experience with medically oriented care plan documentation.
Experience working effectively within a matrix organizational design.
Has valid driver's license and driving record showing no restrictions that would impede ability to
travel by automobile.
Travel Requirement: 50% (variable) by own automobile to assigned local PCP practices. Remainder of
hours worked are based from a home office which must satisfy all HIPAA
The associate is primarily seated while performing the duties of the position. Occasional
walking or standing is required. The hands are regularly used to write, type,
key and handle or feel small controls and objects. The associate must
frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Demonstrates ability to be self-directed, highly organized, multi-tasked capable, and proficient in
problem solving skills.
Demonstrates exceptional oral, written, and presentation skills.
Demonstrates success in influencing patients and providers. Outstanding customer service skills and
ability to adapt approach to various personalities.
Demonstrates ability to work effectively with all levels of administrative and professional personnel.
Demonstrates proficiency with data analysis and ability to organize data in support of reporting needs.
Demonstrates ability to proactively identify and assimilate quality improvement processes into
Ability to extrapolate information from a variety of sources including medical records to create
concise records that accurately depict the medical story of the member.
Comfort with managing multiple tasks and continually re-prioritizing.
Must demonstrate resilience and effectively work in a fast-paced environment with frequently
changing priorities, deadlines, and workloads that can be variable for long
periods of time. Must be able to meet established deadlines and handle multiple
customer service demands from internal and external customers, within set
expectations for service excellence. Must be able to effectively communicate
and provide positive customer service to every internal and external customer,
including customers who may be demanding or otherwise challenging.
Sharecare, Inc. and its subsidiaries are Equal Opportunity Employers and E-Verify users. Qualified
applicants will receive consideration for employment without regard to race,
color, sex, national origin, sexual orientation, gender identity,
religion, age, equal pay, disability, genetic information, protected veteran
status, or other status protected under applicable law.