The Care Coordinator will be responsible for monitoring and coordinating the population health management activities at one or more clinic locations. The primary function of this position will be to coordinate health care services, in partnership with patients and care team members, across the continuum of care, in order to maximize and improve patient health outcomes.
- A high school diploma or equivalent from an accredited school/program required.
- Bilingual (English and Spanish)
- Prior experience as a Medical Assistant is strongly preferred; experience as an EMT, CNA or HH Aid.
- Prior work experience in a clinic, hospital or health care agency setting preferred.
- Knowledge of medical terminology and systems a plus. Must be detailed oriented, organized and have the ability to multi-task and work in a fast-paced environment.
- Must possess excellent customer service and writing skills. Position requires computer literacy; prior electronic health records (EHR) experience strongly preferred.
- Flexible work schedule to meet clinic hours; reliable transportation to access other clinic sites as assigned.
- Identify patients for care coordination via generating patient registries, MCO care gap lists, etc; Conduct timely patient outreach/engagement and follow up activities, via telephone, direct mailing, face-to-face and/or electronically, to new and established patients and to schedule/coordinate appointments as needed.
- Track, monitor, and schedule follow up appointments for patients recently discharged from the hospital or ER; collaborate with Nurses/care managers for patient needs.
- Assist patients, in collaboration with care team, with transitions to care, navigating health care services and linkage to community resources.
- Regularly collaborate, coordinate, and communicate with care team member(s) to resolve outstanding patient care related items (i.e. care gaps; outstanding referrals; follow up paperwork etc.).
- Assist with data collection and reporting for targeted clinical quality measures.
- Assist with closing the loop on outstanding referrals, diagnostic results (ie, labs, x-rays), patient documents and consult reports by following up with patients, specialty providers, hospitals, health plans, community agencies, etc.
- Serve as a resource to the care team and other staff members on the collection and management of population data, patient outreach, tracking of patient progress, and generation of reports.
- Collaborates with nursing staff (RN’s/LPN’s) to identify and refer appropriate patients for complex care management.
- Monitors clinical quality measure outcomes and identifies opportunities for improvement in collaboration with Supervisor.
- Produce, maintain and input timely, accurate, and thorough documentation of all communication directly with and on behalf of patients within the EHR; including consultations/staffings regarding patient care/services.
- Maintain confidentiality of all medical records by adhering to HIPAA guidelines when handling patient information and sensitive documents.
- Implement and maintain department’s process for logging/tracking all patient outreach efforts made (i.e. appointment scheduling).
- Timely and accurate completion of all care coordination tasks and assignments by deadlines.
- Provide back up support and assistance with care team activities (ie, Medical Assistant functions) as needed and assigned.
- Maintain professionalism at all times when communicating with patients, staff members, community partners, external agencies, etc.
- Adhere to all policies, procedures, and protocols of the agency and department.
- Participate in Patient Centered Medical Home (PCMH) and quality improvement (QI) related activities as assigned.
- Participate in chart audits and reviews as needed and assigned.
- Attend meetings and trainings as scheduled.
- Meet individual and department targeted productivity goals, objectives and performance ratings.
- This position requires credentialing and privileging with our agency. Once a conditional offer of employment is made, prior to start, the following must be submitted to the HR Department:
- Copy of Government Issued Photo ID (unexpired) for identification
- Copy of Professional License (unexpired)
- Copy of DEA License AND Registration Card (unexpired) as applicable
- Copy of Board Certification as applicable
- Copy of Basic Life Support Certificate (BLS)
- DCFS CANTS Background Screening
- Three (3) Professional Reference Forms
- Fitness for Duty
- Copy of Immunization Records (MMR and Varicella required; Hep B and Flu are recommended)
- Copy of Negative Tuberculosis PPD test results
- CCHC Request for Privileges as applicable
- Completed Training Form (Continuing Medical Education Units (CMEs) or CEUs Form (within past two years; enclosed)) along with Certificates of Completion as applicable
- State Credentialing Form (Needed for Revenue Cycle) as applicable
- Order Official Transcripts, highest level of education