Clinical Care Coordinator (ACO- House Calls)

• Overview Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents.
• Founded in 1999, we’ve grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women’s health to endocrinology and psychiatry.
• We also provide nursing home support, care management services, and in-home medical services through our House Calls Division, Intention Health Care and facilitate smooth transitions between care settings including telehealth, in-person medical visits, and home care through Intention Health Care.
• Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it.
• We’re looking for talented, motivated individuals to join our growing team.
• Whether you’re a medical provider, administrator, or operations professional, there’s a career here for you.
• Join us in making a real difference in the health of our community.
• Job Summary The Clinical Care Coordinator (CCC) works in collaboration with the primary care provider and all other members of the care team to support chronic disease care management for high-risk, high-need patients in a manner that is medically appropriate and cost effective.
• As a patient advocate, the CCC is responsible for direct and indirect patient care, helps identify clinical and health-related social needs and connects patients with relevant community resources.

Responsibilities

Conduct telephonic and in-person communication with patients to support the provider in addressing patients’ medical and social needs. o Occasionally visit patients in their homes to support proactive and efficient care delivery, and to evaluate patients signs, symptoms, and social needs. o Serve as the contact, advocate, and informational resource for patients, care team, family/caregiver(s) and community resources. o Facilitate patient access to appropriate medical and specialty providers. o Educate and refer patients to community resources. o Develop a comprehensive, collaborative care plan, based on provider treatment plan, evidence-based chronic care guidelines, and patient/family goals for patients to promote adherence to provider recommendations and instructions. o Assist with and facilitate the transition of care from inpatient settings such as hospital, rehabilitation facilities and skilled nursing facilities to home. o Address medication adherence. o Complete daily tasks such as taking clinical notes, reviewing medical records, following up on care gaps, coordinating chronic disease care, and other duties as assigned. o Provide education to patients, families/caregivers regarding resources for health care management, and condition exacerbations. o Communicate changes in patient’s status timely with the care team. o Work with the Administrative staff to provide feedback that can assist in identifying and improving day-to-day operational processes.