Panel Care Coordinator

Job Summary

The Panel Care Coordinator (PCC) assists the Care Team by coordinating care for patients on the provider’s daily schedule and proactively managing care for patients not on the schedule to offer complete preventive care for all patients on the assigned panel. The PCC coordinates services for all patients with serious, complex, or chronic health problems or with psychosocial issues and provides advocacy, information, and referral services to patients and families to address medical and psychosocial needs.

• Review provider schedules, individual patient charts, and assist the care team in coordinating care for visits and future healthcare needs.
• Handle non-appointment related calls from patients; resolve the reason or route to the appropriate party.
• Provide an effective communication link between patient and medical staff, including relaying messages from providers, gathering information from patients for providers.
• Support patients and providers in medication refill process.
• Use registry and other information to inform care team members of preventive care required for each patient seen each day.
• Ensure all patients are tracked and data entered into systems for follow-up and reporting.
• Regularly review registry information for assigned panel of patients and arrange care needed to proactively coordinate healthcare needs.
• Coordinate with medical staff to ensure case management services are provided to patients with complex medical and/or psychosocial problems.
• Work with medical staff to develop, implement, and carry out programs in chronic disease management for patients with conditions such as diabetes, asthma, congestive heart failure, hypertension, and depression, based on chronic disease management model.
• Assist in coordination of care with pharmacies, insurance companies and other community providers; ensure information goes when and where needed.
• Ensure disease and other registry data entry is up to date and use registry reports to organize plan of care for complex patients on assigned panel.
• Participate in team decisions regarding data requirements for proactively managing the team’s panel.
• Use and update the directory of resources in the service area to meet basic health and human needs; be facility at using the resources available within the Center.
• Act as a backup to other Panel Care Coordinator or other care team members as needed.
• Perform other duties as assigned.
• Ability to handle protected health information (PHI) in a manner consistent with HIPAA.

• Proficiency in verbal communication in English and Spanish and understanding of basic written English and Spanish.
• Demonstrated ability to work effectively in a team environment.
• Demonstrated problem solving skills in a complex environment.
• Demonstrated effective interpersonal relationship and customer service skills.
• Good organizational and time management skills.
• Good working knowledge of local social service resources or skills to acquire and use this knowledge expeditiously.
• Desire to work with the Hispanic community and carry out the mission of the Center.
• Ability to work effectively with people from diverse cultures and diverse socioeconomic situations.
• Basic level of skill with Microsoft Word, Excel and ability to use other computer programs and applications (Epic, Meditracks, etc).

• One of the following is required:
  Associates Degree in Healthcare Administration, Social Science, Social Work, or related (preferred);
  Medical Assistant Certification; or Four years of experience in a healthcare or social service-related administrative role.
• Two years prior experience working with underserved populations preferred.
• Communication skills, spoken and written, equivalent to 2 years of college education.

• Standing: 5%
• Walking: 15%
• Sitting: up to 75%
• Lifting/Carrying: 5% - up to 40 pounds.

• Computer: data entry, word processing and database programs, internet, e-mail.
• Telephone, Fax, Copier.
• Equipment commonly used by Medical Assistants for CM's who will also act as a back-up to the team's MA.

Staff member must meet immunization requirements as stated in…