Description

Job Location:

Greenfield/Amherst, MA

Job Schedule:

Full Time

Standard Hours

40 / Non-exempt

Job Shift

Shift 1

Reports to: Program Manager for Care Management

Shift Details

Mon-Fri

Job Description Summary

Under the direction of the Program Manager for Care Management, responsible for a wide variety of duties related to medical outreach to patients and clinical data entry. Major responsibilities/accountabilities include outreach to patients in a professional, respectful manner; work collaboratively with the practice-based Nurse Care Manager, provide social care management, close gaps in care, manage transitions of care, and to accurately and efficiently enter clinical data.

The Outpatient Care Coordinator is responsible for proactively helping patients and their families navigate and access health and community services while adopting healthy behaviors. Works to promote, maintain, and improve the health of patients and their families by providing social support. Communicates and coordinates with all entities involved in the care of a patient to promote and maximize care coordination and patient satisfaction for a population of patients. Follows up with patients that have been in the Emergency Department/Inpatient to facilitate PCP follow up and identify unmet needs, under the direction of the Nurse Care Manager. Maintains clear, concise, objective and accurate documentation of patient encounters. Conducts Health Risk Assessments and Orientations to the practice and refers patients appropriately to the Nurse Care Manager. Screens/Identifies/Outreaches to patients to assure needs for preventive care and disease management are met. Performs home visits, if applicable, to a subset of patients. Develops and implements a personal development program to ensure continuing professional growth. Observes all health and safety requirements.

Adheres to system and department compliance policies, and all applicable laws/regulations.

Performs other additional duties as assigned.

Job Requirements

Develop and maintain excellent working relationships with patients, providers and their practice staff, as well as other key stakeholders along the continuum (e.g., Inpatient, Post-Acute)

Quality Management: Utilize registries as well as standing orders to proactively identify and outreach to patients that need preventive screenings/chronic disease testing. Assist patients in scheduling appointments and tracking until the results are received. Collaborates with the care team to track, monitor and report on specified disease-related and patient tracking measures.

Transitions of Care: Provide outreach calls, per protocol, to patients that have been discharged from the hospital or the emergency room. Review discharge instructions, ensure follow up appointments are made, screen for care management.

Promote timely access to appropriate care while increasing the utilization of preventative care, managing referrals, transitions-in -care, and reducing emergency room utilizition and hospitalization.

Care Coordination: Provide ongoing support and coaching to a subset of patients needing care coordination, resource linkage, self-management support.

Link patients to community resources and track to ensure services are in place.

Work in collaboration with the Nurse Care Manager to ensure care coordination activities are provided to maximize outcomes for the patient.

Prescreens patients for complex care management utilizing a Health Risk Assessment.

Provides clear, concise documentation in the patient’s Medical Record, as well as the Care Management system.

Performs home visits, when necessary, to a subset of patients.

Continuously expand knowledge and understanding of community resources and services, public health prevention, and evidence-based intervention programs provided.

Enters necessary orders based on standing order protocols, within scope of practice.

Skills/Competencies:

Required: Excellent written and verbal communication and interpersonal skills are a must. Capacity to work closely with patients, physicians and their office staff and managed care plans. Strong organizational and prioritization skills. Attention to detail and able to perform work independently.

Qualifications

Minimally Required Education:

High school diploma or GED

Graduate of an accredited Medical Assistant program

Minimally Required Experience:

Credentialing must be awarded by a third-party credentialing body which can be obtained through one of the following:

• Certified through the American Association of Medical Assistants (AAMA)
• A Registered Medical Assistant (RMA) Registered as an American Medical Technologist (AMT)
• Certified Clinical Medical Assistant (CCMA) through the National Healthcare Association

3-5 years of experience working as a Medical Assistant.

MA Driver’s License Required.

Why Choose Baycare:

BE HEALTHY, STAY HAPPY!

Baycare offers low-cost medical, dental and vision plans for all qualifying employees and their eligible dependents. Reimbursement for a variety of wellbeing activities, included but limited to gym membership and equipment, personal trainer, and massage.

SAVE FOR RETIREMENT

We offer a 401(k) Plan with employer safe harbor contributions to all eligible employees.

TIME TO RECHARGE

We respect the fact that our employees have lives outside of work, and we offer competitive PTO.

BE A LIFELONG LEARNER

Baycare has a tuition reimbursement program to support eligible employees who wish to continue their education to work towards increased professional responsibility and growth.

PEACE OF MIND

To help protect our employees, we offer fully company-paid life insurance as well as short- and long-term disability coverage.

WORK TOGETHER. PLAY TOGETHER

We work hard at Baycare, but we value fun and camaraderie outside of the office. Employees are invited to join in activities like fun runs for a charitable cause, summer barbecues, and our annual party.

FLEXIBLE AND FRIENDLY

Here at Baycare, we know that life doesn’t always go to plan. Our family-friendly office helps employees stay on track when life throws a curve ball.

REWARDING EXCELLENCE

We recognize that our employees are our greatest strength. From email shout-outs to performance bonuses, we make it a point to let our employees know how much we value their contributions.

We offer competitive total compensation that includes pay, benefits, and other recognition programs for our employees. The base pay range shown considers the wide range of factors that are considered in making compensation decisions including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors. This base pay range does not include our comprehensive benefits package and any incentive payments that may be applicable to this role.

Equal Employment Opportunity Employer
Baycare Health Partner is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.