Care Coordinator

Description

JOB TITLE: Care Coordinator

LOCATION: Ontario 

HOURS: Full Time

STARTING DATE: ASAP

STARTING PAY: Commensurate with experience

REPORTS TO: Director of Nursing/Practice Manager

Purpose of this Position: The Care Coordinator is a key member of the medical home team, using registries and evidenced-based guidelines to drive the proactive care process for clinic patients. The role of Care Coordinator is to facilitate communication, coordinate services, address barriers, and track the health of the patient population assigned to a provider panel in accordance with the goals and mission of Valley Family Health Care.

Requirements

QUALIFICATIONS:

1. Associate degree in appropriate field (public health, health administration, or other health related field), or MA, LPN, or RN licensure.
2. At least 2 years of experience in the fields of health, public health, or social service; an emphasis on community and population health and care coordination is desirable.
3. Excellent organizational skills and strong written and verbal communication skills.
4. Strong computer skills, particularly in Microsoft Office – Word, Excel, Outlook, PowerPoint, OneNote & the Internet.
5. Able to build and maintain effective partnerships internally and externally with an awareness of community resources.
6. Able to work with patient/client groups and/or experience in membership organizations.
7. Able to work with minimal supervision and maximum accountability to problem-solve and work independently and collaboratively as a member of a team.
8. A professional demeanor, pleasant manner in telephone and personal contacts.
9. Analytical skills with the ability to manage and prioritize multiple tasks.
10. Fluent in written and spoken English. Spanish fluency desirable.
11. Valid Driver’s License and clean driving record.

RESPONSIBILITIES:

1. Participate in the delivery of team-based care in assigned clinic(s).
2. Utilize registries, electronic reports, and review of provider schedules to proactively coordinate preventive screening, care coordination, and communication, documentation of measures and interventions via EHR. Assure that care is patient-centered.
3. Use clinical evidence-based care guidelines to monitor patient health status and need for services by coordinating high-risk patient risk reduction, hospital and ER utilization, and improvement of patient outcomes.
4. Collaborate with team members for appropriate tracking and follow-up of referrals, in conjunction with the central referral desk staff.
5. Notify appointment schedulers of patient needs for visits based on recall and evidenced-based care guidelines.
6. Follow up with patients as requested by provider.
7. Assist in education, assistance, support for patients and families, and care coordination with outside providers and community resources.
8. Assess patients’ readiness to change, monitor compliance with plan of care, and problem-solve barriers related to the health care system, financial, and psychosocial barriers.
9. Utilize behavioral strategies to assist patients in adopting health behaviors, improving self-care and managing chronic disease.
10. Assist Outreach and Enrollment staff with patient’s eligibility requirements for Medicaid, SSI, etc. and with coordination of enrollment with service agencies.
11. Make reminder calls for patient visits, to include but not limited to the guidelines set forth by VFHC for PCMH, PCPCH, and MU.
12. Review Medicare, Medicaid, & other Payer GAP reports and coordinates care with patients accordingly. Notifies schedulers of Medicare annual wellness visits needed.
13. Collect data and develops reports incorporated into the Quality Improvement Programs.
14. Participate in VFHC meetings and committees as assigned.
15. Assist with meeting quality measures by completing tasks related to VFHC initiatives.
16. Perform other duties as assigned.

Physical Requirements:

1. Ability to lift 25lbs.
2. Prolonged sitting/standing/walking/stooping, etc.
3. Correctable vision and hearing.
4. Manual dexterity.
5. Must be able to read, write and speak clearly.