Care Coordinator

Primary Responsibilities and Duties

• Collaborate with healthcare providers, administrators, and other members of care team to deliver population health programs and interventions.
• Manage a panel of patients, working collaboratively with health center staff to engage patients into care, close gaps in care, manage referrals, coordinate preventative care, and schedule recommended appointments.
• Prioritize patients for program outreach utilizing available information, such as reports from health plans, risk stratification, software system and data review, referrals from hospitals and providers and patient self-referral, reports, or other data.
• Assign patients to appropriate care managers based on available information.
• Provide timely feedback to referral sources.
• Review patient lists for needed care.
• Assist with pre-visit information documentation and patient outreach for lab, test, and appointment reminders. Ensure barriers to appointment attendance are identified and mitigated.
• Facilitate/assist with daily team huddles, as appropriate.
• Coordinate education, brief intervention and/or facilitation of referrals to and from providers, practice staff, and community-based organizations and other programs/services in accordance with applicable protocols.
• Coordinate ancillary assistance for patients to assess and address psycho-social barriers that limit engagement in care including advocacy, support and assistance with transportation, health insurance, scheduling, and keeping appointments, and interpreter assistance, as necessary.
• Perform basic administrative duties with high degree of accuracy including note taking, managing team schedules, ordering supplies, arranging office set up, patient registration, reminder phone calls, writing letters, formulating emails, scheduling appointments and meetings for patients and team members, record keeping; and maintaining all forms, databases, protocols, and manuals.
• Track patient data, stratify patient registries, and facilitate provider follow up and referrals to community-based organizations. Generate reports as requested.
• Handle confidential information in accordance with HIPAA as well as other related federal and state confidentiality rules.
• Identify patients at high risk of adverse health outcomes through case finding activities including risk stratification list, provider referrals, or encounter data review identifying high cost/high risk disease states or patients.
• Engage patients in trusting relationships enabling effective intervention and support. Ensure patient understands program benefits, care manager’s role, how to make best use of the program, and obtain consent to participate.
• Apply motivational interviewing to conduct assessment(s) of patient condition, needs, preferences, clinical and psychosocial/SDOH barriers to optimal health and identify care/case management intervention opportunities.
• Support the patient in identification of actionable goals to optimize health outcomes.
• Assist with data entry and management for closing gaps of care.
• Work with Excel spreadsheets to provide concise, meaningful data back to the team.
• Attend team meetings, trainings, learning events, and other functions, as required.
• Participate in measurement of care/case management program effectiveness.
• Certified medical personnel (RMA/CMA, etc.) must function under the direct supervision of a physician, Registered Nurse, or Advanced Practice Provider. This role is a supportive one and does not involve making independent decisions regarding infection control practices.
• Performs other duties as assigned.

Qualifications

• This position requires a high level of professionalism, strong communication and interpersonal skills, and the ability to handle sensitive and confidential information with discretion.
• Organizational Skills - Displays more advanced organizational skills, to organize projects or the work of others.
• Problem Solving Skills - Devises effective solutions to situations encountered which include general goals and objectives.
• Communication Skills - Able to effectively communicate opinions drawn from conclusions using inference and logic.
• Critical Thinking Skills – Uses logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems.
• Problem Resolution - Resolves conflicts that may arise because of disagreements between employees, between employees and customers/clients.
• Processes work-related skills at a higher level than completion of high school, including formal written and verbal communication skills, computational and computer skills, mathematical, technical or health care related knowledge frequently acquired through a trade school, paraprofessional, or certificate type program.
• Possess specific knowledge of healthcare processes and practices typically acquired during completion of a certified medical assistant program or health related care program.
• Required: Certification or licensure in health care related field (i.e.: CMA/RMA, LVN) or compensatory experience with possession of a high school diploma or General Educational Development (GED).
• Required: 6 months of medical assistant related experience.
• Required: Completion of updated BLS/CPR.
• Required: Valid state Driver’s License or with reliable transportation.
• Electronic Medical Record Skills - Demonstrates necessary proficiency with all electronic clinical systems, including EHR and scheduling systems, in use at the health center.
• Familiarity with medical terminology, procedures, and pharmacology, including medication administration procedures.
• Proficient with general medical machines and equipment: Patient Scales, stethoscope, glucometers, PFT testing, Nebulizer treatment administration, medication administration, lab, EKG.
• Proficient with typical office equipment: Copier, telephone, Fax.
• Possesses a level of written and verbal communications, including formal written and verbal communication skills frequently acquired through a trade school, paraprofessional, or certificate type program.