Brief Description

The Care Coordinator is the “link” to ensure a continuity in coordination of patient care through his/her collaborative interaction with all the community relationships involved in that care – including but not limited to – the labs, hospitals, patients themselves, and patient’s healthcare plan (i.e. Medicaid, Managed Care Plus). Ensures all information is communicated clearly on behalf of the patient and between collaborative partners for the primary benefit, comfort and well-being of the patient.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Collaborative Partner Coordination of Services:

• Assists clinical directors in maintaining compliance with meaningful use standards.
• Follow-up consistently on transitional care for patients.
• Ensure appropriate frequency of patient visits to maintain for the team and the patient a proper continuum of care.
• Promotes clear communication amongst care team and clinicians by ensuring awareness regarding patient care plans.
• Coordinates continuity of patient care with external healthcare organizations, facilities, and payers including the process of hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
• Becomes knowledgeable in and keeps updated on Pillars Community Health’s payer contracts as they relate to patient access, referrals, pre-authorizations and clinical indicators measures.
• Manages patient rosters to patient’s risk factors and assures prompt access to Pillars Community Health services.
• Utilize electronic health record (eCW) to document patient contacts related patient education, resource connection and external care providers.

Patient Centered Care:

• Manage potential risks and liabilities within the health center to minimize risk of errors, accidents and other adverse incidents by completing incident reports in a timely manner and submitting to supervisor
• Pay close attention to EMR system notes and alerts, routing information appropriately to correct team members for quality patient care.
• Assist in management of high-risk patient care including management of patients with multiple co-morbidities or high-risk for readmission to a hospital setting, including a registry.
• Coordinates continuity of patient care with patients and families following hospital admission.
• Supports patient self-management of disease and behavior modification interventions.
• Communicates with patients, patient support systems and peers from a trauma informed perspective

Continuous Quality Improvement:

• Be a voice for strictly adhering to the Pillars Community Health Quality Improvement Plan, and work with the staff to assure compliance.
• Work closely with the QI Manager and/or Risk Manager to assure HIPAA compliance in the sharing of PHI with collaborative partners on behalf of patient.
• Participate in training programs that focus on the components of the Quality Program.
• Report compliance problems and patient data to immediate supervisor, QI Manager and/or Risk Manager regularly as required

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and or ability required. Reasonable accommodations may be made to enable an individual with a disability to perform the essential duties and responsibilities.

EDUCATION AND EXPERIENCE

• Bachelor’s degree from an accredited college or university with a background in health-science, public health, behavioral science or other similar degree. Combination of education and experience may be considered in lieu of degree.
• Medical Assistant background required.
• Case management experience preferred
• Public Health educational focus
• FQHC background or experience in outpatient setting highly preferred
• Meets company health & immunization/vaccination requirements

LANGUAGE:

Bilingual Spanish/English skills required