Position Summary:  

The Patient Care Coordinator works with patients referred for assistance in accessing and utilizing health care resources due to their complex chronic illness and preventative screenings and improves health outcomes through coordinating care, educating patients, building trust between patients and medical practitioners, and enhancing communication and the continuity of care.

Essential Functions:

Clinical

1. Performs intake assessment which includes obtaining and reviewing prior medical records and medical or program-related information and assessing cognitive/verbal skills and needs and identifying barriers to accessing healthcare 
2. Understands and acts upon orders to include laboratory testing, immunizations, TB skin testing and referral for preventive health needs as indicated per disease management protocols 
3. Monitors patients frequently for changes in health status after initiation of a new medication, recent hospitalization, or change in health status
4. Follows-up with patients when barriers to referrals are identified
5. Routes calls to triage and facilitates a response to urgent telephone calls, requests or visits from assigned patients
6. Assists with arranging supportive services as needed
7. Provides counseling and facilitates screening as ordered
8. Assist patient with goal-setting to achieve behavioral change
9. Participates in regular staffing meetings focused on coordinating patient care within an interdisciplinary team, keeping the team updated on patients’ conditions and circumstances by utilizing morning huddles.
10. Consults with other health care team members to coordinate the services of patient education, preventive care and disease management
11. Other duties as assigned

Educational and General

1. Teaches, counsels and follows-up with assigned patients on health issues relevant to his or her care  
2. Performs individualized assessment of patients’ educational needs and provide tools to assist patients in managing their disease(s) effectively
3. Provides individual and family educational interventions including self-management goal-setting, counseling and training on the habits, lifestyle changes, supplies and tools necessary to manage their disease
4. Provides individual counseling on office procedures and importance of a primary care medical home and other health issues. Provides referrals for eligibility of programs and services.
5. Facilitates group classes covering topics which build skills in self-management of one or more chronic diseases
6. Assists in the development and maintenance of a library of educational resources including written materials and videos, on related health issues 
7. Serves as a consultant to the rest of the health care team for educational resources, reviewing them for language, cultural competency and reading level
8. Assists in gathering and compiling data to direct the most effective use of educational interventions
9. Follows-up with patients to assess whether educational objectives are met and determine need for refresher interventions 
10. Holds all patient Protected Health Information (PHI) and other patient personal information as well as agency association information in confidence, in accordance with HIPPA and Heart City policy
11. Participates in quality assurance and improvement meetings, special projects, observances and/or activities that advance the mission, goals and objectives of Heart City Health Center