The Care Coordinator is responsible for coordinating care and guidance to primarily at-risk patients from diagnosis to survivorship. Uses evidence based research to formulate the plan of care and ensure that patients at risk are following their protocols. Documents outcomes and maintains database of patient QI initiatives and outcomes. Coordinates the appropriate resources and consult services to provide continuity of care and appropriate follow up plan of care. Communicates with all members of the healthcare team. Initiates appropriate patient teaching based on needs. Supports the patient in decision making, may assist in coordination of end of life care if necessary. Develops effective interpersonal relationships with patients and works collaboratively with the interdisciplinary care team to improve health outcomes. Utilizes internal and community resources, electronic medical record and Centers for Medicare and Medicaid data to educate patients and form a c...