Care Coordinator

The care coordinator identifies gaps or barriers to care, schedules wellness or other care gap visits, coordinates patient care, patient education, and communicates with patients, providers and care teams. He/she works with members of the healthcare team to facilitate, promote and support patient healthcare, as well as build awareness among the healthcare team and let them know about patient care coordination/navigation services. All Juniper Health employees will adhere to the Patient Center Medical Home (PCMH) model and work to ensure that patients of all ages receive comprehensive, coordinated and patient-centered whole patient care. The employee will maintain confidentiality at all times.

ESSENTIAL FUNCTIONS:

• Disseminate daily huddle report to clinic managers in an effort to address care gaps during visit. Work with Patient Navigators to assist nursing staff in records requests to obtain records for preventative screenings and others records as required.
• Assist in tracking referrals as appropriate by working closely with the Referral Clerks and Patient Navigators to ensure the referral loop is closed in a timely manner.
• Completes documentation in EMR for any referral tracking, patient record requests, appointments scheduled and other records as assigned.
• Coordinate with Director of Quality Improvement, Director of Operations, Clinic Manager, Referral Clerks and Patient Navigators in team meetings as requested.
• Use appropriate technology tools to accomplish job functions; understand and utilize available technology as customer service, communication and data gathering tools as appropriate.
• Perform related duties as assigned by supervisor
• Identify gaps in care by reviewing reports from population health software reports; contact patients with delinquent screenings and/or care gaps and schedule appointment; follow-up to make sure appointments are kept.
• Submit completed care gap reports to Director of Quality Improvement.
• Export and submit chart documentation to insurers to meet HEDIS measures; Ensure restricted information is properly excluded from exports.
• Other duties as assigned.

REQUIREMENTS:

• Education: High School Graduate or General Education Degree (GED): Required
• Experience: Five years of experience in community health or in another position with the provision of health and/or social services, support highly preferred. Experience with HEDIS measurements and population health management preferred.
• Computer Skills: Computer data entry, basic computer operating skills, Excel, Word, and EMR (Electronic Medical Record) preferred
• Certifications & Licenses: CNA or MA certification preferred.

WORK ENVIRONMENT:

• Work is typically performed in an office setting.

PHYSICAL DEMANDS:

• The physical demands required of the position are representative of those required of comparable professional positions and must be met by the employee to successfully perform the essential functions of the job. While performing the duties of this job, the employee is required to communicate, operate equipment, observe details at a close range, be in stationary or moving positions, and occasionally lift or move up to 25 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions. Please see Human Resources to discuss.

TRAVEL:

• Travel to JHI sites and/or external meetings and trainings may be required.

OTHER:

• The employee is expected to work and be available during regular business hours, however, extended hours and weekend work may be required.