The Patient Care Coordinator assists primary care teams by managing patient panels and coordinating care for high-risk patients to improve health outcomes. Responsibilities include scheduling follow-ups, conducting patient outreach, and providing education to improve self-management skills.
Requirements summary
Candidates must have a high school diploma or GED, a Medical Assistant Certificate, and a current BLS certification. Experience as a medical assistant in a medical home or non-profit community health setting is preferred, along with bilingual skills in English and Spanish.
high schoolprofessional certificateOrganizational SkillsTeam CollaborationSchedulingElectronic Health RecordsPatient EducationCare CoordinationClinical DocumentationCritical ThinkingPatient EngagementBilingual CommunicationPatient CoordinationPrior AuthorizationChronic Disease ManagementPanel ManagementPopulation ManagementMedical Home Model
Job description
Community health is about more than just vaccines and checkups.
It’s about giving people the resources they need to live their best lives.
At Neighborhood, this is our vision: a community where everyone is healthy and happy.
We’re with you every step of the way, with the care you need for each of life’s chapters.
At Neighborhood, we are Better Together.
As a private, non-profit 501(C) (3) community health organization, we serve over 500,000 medical, dental, and behavioral health visits from more than 100,000 people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.
Since 1969, our employees have been making this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If this sounds like an organization you would like to be a part of, we would love to meet you.
The Patient Care Coordinator will assist primary care practice (PCP) teams to improve patient health outcomes. This role will assist with coordinating and providing panel management services to patients at highest risk for health deterioration and assisting patients achieve their self-care goal by increasing access to health services and resources.
This is a full-time temporary position, expected to last 3-6 months.
Schedule
Monday-Friday, 8am-5pm. This position is onsite.
Responsibilities
Utilizes the primary care medical home model to provide coordinated team care to address current diseases
Provides panel management for preventative and health maintenance follow-ups for the maximum number of patients per day
Contacts new patients to provide a warm welcome to our clinic, explain the medical home, and answer patient questions
Schedules patients with chronic conditions for follow-up appointments per preventative and maintenance care schedules
Performs population management tasks, such as appointment scheduling, recalls, web portal callbacks, and addressing telephone encounters
Makes outreach calls to patients missing appointments based on preventative and chronic disease guidelines
Delegates ECW telephone encounters and Web Portal messages to medical assistants and providers
Implements actions for increasing productivity, such as scheduling patients for PCP follow-up visits, anticipating open slots for same day appointments, and proactively maintaining full provider schedules
Tracks and reports the progress of assigned tasks and logged PCP discussion topics in weekly supervisor meetings
Collaborates and supports the PCP to identify and implement actions for improving population management and patient care outcomes
Organizes weekly pre-clinic team huddles to update progress on various goals, such as Meaningful Use compliance and C.A.R.E. Transformation
Coordinates monthly medical assistant team meetings to discuss progress towards PCMH goals and areas needing improvement
Provides and documents patient end-of-visit interviews, coaching, and patient engagement conversations
Reinforces information given to patients and/or family with handouts to improve patient self-management skills and communication
Provides education to patients during medical appointments, as needed
Acts as first point of contact for patients and families asking questions and raising concerns through the patient web portal and via phone
Submits prior authorization for medications, DME supplies, and other items, as needed
Impacts patient experience by demonstrating values of Transforming Care, including courteous and helpful behavior and a commitment to accuracy
Shares accountability for overall patient health outcomes by working in coordination with PCP
Completes ECW notes for all care coordination and other services provided in a timely manner
Prioritizes activities according to need and required follow-up
Provides accurate and timely reports to supervisor, as required
Contributes to the success of the organization by participating in quality improvement activities
Operates to instill confidence in our care and in our facilities to patients, fellow employees, and other stakeholders
Assists medical assistants and patients as needed
Qualifications
Education/Experience
High school diploma or GED required
Medical Assistant Certificate from an accredited program required
Current Basic Life Support (BLS) certification required upon hire and must be maintained as a condition of employment. These courses must follow AHA guidelines- may be completed through approved online providers such as ProMed or other equivalent programs that meet recognized BLS standards
One year of medical assistant experience within a medical home health preferred
Non-profit community health clinic experience preferred
Bilingual (English/Spanish) highly preferred
Diabetes and hypertension education experience preferred
Additional Qualifications (Knowledge, Skills and Abilities)
Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
Knowledgeable about and experience with medical home health
Ability to adapt to changing patient or organizational priorities
Ability to successfully manage multiple tasks simultaneously
Ability to use critical thinking to make decisions and problem solve.
Excellent planning and organizational ability
Ability to work as part of a team as well as independently
Ability to work with highly confidential information in a professional and ethical manner
Physical Requirements
Ability to lift/carry 20 lbs/weight
Ability to stand for long periods of time
Pay range
$27.21 to $38.10 per hour, depending on experience.
Compensation Disclosure
The posted salary range reflects the designated pay grade for this position. While this range represents the broader classification of the role, actual compensation will be based on several factors, including but not limited to the candidate’s overall knowledge, skills, and experience, market data and industry benchmarks, internal equity within the organization, Budgetary considerations and organizational needs. As a result, placement within the range is not guaranteed, and the full pay grade range may not be utilized.
