The Patient Care Coordinator connects patients with medical resources and support systems while facilitating communication between patients and healthcare providers. They educate patients on the PCMH model and support measure improvement efforts for ACO and IPA initiatives.
Requirements summary
Candidates must have a high school diploma and at least two years of experience in community outreach, resource development, or casework. Proficiency in computer applications is essential, and a CMA certification or bilingual skills are preferred.
high schoolprofessional certificateTeamworkCase ManagementConfidentialityCommunication SkillsProject ManagementElectronic Health RecordsPatient OutreachCommunity Resource DevelopmentChronic Disease EducationMedical Resource Coordination
Job description
Position Summary
Employee reports directly to the Director of Quality Assurance. The Primary duty of the Patient Care coordinator is to connect patients with medical resources and support systems and to facilitate interaction and communication with healthcare staff and providers. The Patient Care Coordinator may be required to attend Administrative meetings. The Care Coordinator serves as the bridge between the Patient Care Plan and support of patients’ lifestyle needs.
Description of Responsibilities
Educates patients on the importance of a medical home and the difference between Primary Care and care under the PCMH model.
Provides between-visit patient outreach to assigned/referred patients with 2 or more chronic illnesses who show a consistent pattern of out-of-range values for our inclusionary criteria/targeted measures.
Assists service departments (nursing staff, Nurse Manager/Director, Provider) toward improving patient visit consistency, partnership, and health outcomes.
Supports medical home processes (i.e., treatment team and huddle meetings, as needed.
May be required to oversee and evaluate the performance of other staff.
Links assigned patients with appropriate resources and referrals.
Supports insurance payors, as assigned, with measure improvement efforts - external portal measure validation and re-scheduling to close SMC patient care gaps.
Maintains personal knowledge base of available resources, both in-house and within local communities.
Assists with the preparation of administrative reports.
Provide updates of patient progress to be placed in the EHR.
Provide system-based educational material, prevention handouts and assist with distribution of literature for chronic disease states such as Hypertension, Diabetes, Obesity, Depression, Pediatric Asthma (Asthma Action plans), and HIV linkage to Care.
Assist patients in completing computer-based surveys regarding level of understanding of their chronic disease state.
Support measure improvement activities through our Accountable Care Organization (ACO, Medicare effort) and Independent Practice Association (IPA, Medicaid effort).
Support patient forum events.
Other related duties as assigned.
Knowledge, Skills & Responsibilities
Excellent oral and written communication skills.
Ability to maintain confidentiality of information to include protected health Information.
Ability to work as a member of a team and promote teamwork with other staff members.
Ability to work with patients in a compassionate, non-judgmental manner.
Ability to work and act independently.
Effective knowledge and use of computers and multiple programs for daily work and projects.
Understanding of the potential business impact of social media.
Ability to manage multiple projects.
Minimum Qualifications
Must have a High School Diploma and at least two (2) years of experience working in community outreach, community resource development or casework participation.
Basic knowledge of computer applications is essential.
Carries out independent fieldwork, maintains records, and participates in cooperative efforts with numerous agencies and programs.
Bilingual a plus.
Certified Medical Assistants (CMA) are preferred.
Typical Physical Demands
Requires some standing/walking/sitting. Requires travel from one site to another. Use of telephone required.
Typical Working Conditions
Eight (8) hour workday. Some contact with patients and staff
