Clinical Care Coordinator

Overview

The Care Coordinator is responsible for providing assistance to the care management team by working collaboratively to support patient care plans and needs. Serving as an advocate for patients, the Care Coordinator will be part of the care management team and work in tandem with care managers, healthcare providers and community-based organizations to improve outcomes for patients they serve. Working within his/her scope of practice, this role coordinates between health care services, recognizing the holistic needs of the patient, inclusive of patient specific social and cultural dynamics.

This position will support CCHC goals and objectives in meeting performance improvement targets, meeting expectations of standardizing the plan of care, and supporting team development.

• Engages with patients to identify and address barriers that impede health outcomes
• Implements and support Care Management interventions per the patient’s care plan or assessed community needs
• Processes referrals from members of the multidisciplinary team (social work, behavioral health, community resource coordinators, pharmacy, pharmacy technician, care managers) appropriately, accurately and timely according to established workflows
• Schedules home visits and/or practice encounters with patients via phone or correspondence based on referrals
• Documents all interactions with patients/others appropriately in the care management software
• Schedules/verifies appropriate medical appointments for patients as needed
• Coordinates referrals to outside agencies as directed by interdisciplinary team in a timely fashion
• Provides education to patient/family within scope of practice
• Serves as a liaison among the patient/family, community services, primary providers, specialists, and other care team members to coordinate services
• Maintains appropriate documentation in the Care Management documentation platform, in accordance with organizational policies and procedures
• Participates in Quality Improvement initiatives to improve efficiency and effectiveness of patient health outcomes
• Adheres to CCHC privacy and security policies
• Abides by Health Center guidelines, policies and procedures, and HIPAA regulations
• Attends departmental and corporate meetings, local and regional trainings, or other events as required
• Willingly performs other duties as assigned
• Provides educational information to care team, patients, family and care givers, about community-based organizations (existing and new) within service area
• Works under the direct supervision of the Chief Compliance and Nursing Officer.

• High School graduate or GED; completion of certificate program in healthcare area of focus. Current and active certification or licensure from an accredited school or program
• Minimum of (3) three years of experience in an ambulatory/care management or acute care setting, home health, or public health
• Evidence of essential leadership, education, counseling skills, and strong interpersonal skills; ability to work with colleagues across sites.
• Proficiency in communication technologies (email, cell phone, etc.)
• Highly organized with ability to keep accurate notes and records
• Experience with health IT systems and reports is desirable
• Local knowledge about and connections to community health care and social welfare resources is desirable
• Bilingual preferred but not required
• BLS/CPR (or earned within 90 days of hire)
• Ability to travel to other clinical sites when needed

• Core values consistent with a patient- and family-centered approach to care
• Demonstrates professional, appropriate, effective, and tactful communication skills, including written, verbal and nonverbal
• Demonstrates a positive attitude and respectful, professional customer service
• Acknowledges patient’s rights on confidentiality issues, maintains patient confidentiality at all times, and follows HIPAA guidelines and regulations
• Proactively acts as patient advocate, responding with empathy and respect to resolve patient and family concerns, and recognizes opportunities for improvement to meeting patient concerns
• Proactively continues to educate self on providing quality…