What are the responsibilities and job description for the Care Connector and Transitions of Care Coordinator position at Alcona Health Center?
Care Connector and Transitions of Care Coordinator
Job ID: A25-011
Location: Harbor Springs
About Our Family:
Established in 1978, Alcona Health Center (AHC) is a non-profit, Federally Qualified Health Center dedicated to making a lasting impact in the Northern MI communities we serve, offering medical, behavioral health, dental and pharmacy services. As a member of the AHC family, you will join a team of over 300 coworkers, all devoted to providing quality health care to all residents of our communities, regardless of their ability to pay.
Your Valued Contributions:
Coordinates and facilitates post-acute care for patients. Collaborates with and contributes to the transitional care team's plans of care. Identifies and utilizes appropriate resources to optimize effective, efficient care plan goal achievement. Provides support to patients and families, linking them to appropriate community resources.
Location: Harbor Springs
About Our Family:
Established in 1978, Alcona Health Center (AHC) is a non-profit, Federally Qualified Health Center dedicated to making a lasting impact in the Northern MI communities we serve, offering medical, behavioral health, dental and pharmacy services. As a member of the AHC family, you will join a team of over 300 coworkers, all devoted to providing quality health care to all residents of our communities, regardless of their ability to pay.
Your Valued Contributions:
Coordinates and facilitates post-acute care for patients. Collaborates with and contributes to the transitional care team's plans of care. Identifies and utilizes appropriate resources to optimize effective, efficient care plan goal achievement. Provides support to patients and families, linking them to appropriate community resources.
Provides outreach services in the community and in the clinics in an effort to improve patient care and outcomes.
As a Care Connector:
- Patient Care Activities
- Checks external health information systems (examples: EPIC, Sunrise, GLHC ADT’s, Carespective, etc) as well as the ADT folder, for Alcona Health Center patients with recent emergency department discharges.
- Contacts patients with recent emergency department discharges, schedules follow-up visits with PCP as needed, educates on after hours, on-call, and walk-in services available
- Systematically works insurance gap reports; generates and monitors internal gap reports and needed services from the EMR.
- Educates patients on needed services including annual exams, recommended screenings, tests, and labs.
- Assists patients with scheduling of appointments to address gaps in care or needed services.
- Submits required documentation to insurance companies to close gaps that patient has already completed.
- Obtains diagnosis gap reports from insurances and addresses these with the patient’s PCP. Faxes completed documentation or reports online, per insurance reporting requirements, to close diagnosis gaps.
- Assessing patient attribution and completing provider change requests on patients when needed.
- Patient Centered Medical Home:
- Proactively supports PCMH initiatives related to care coordination.
- Proactive member of care teams in team based care initiatives.
- Communication and Documentation:
- Thorough and timely documentation of all contact or attempted contact with patients.
- Establish and maintain positive working relationships with insurance representatives for all insurances to ensure we have the most up-to-date requirements for closing gaps in care.
- Communicates gaps in care and needed services with care team through the EMR.
- Systematically tracks activities to ensure patient compliance.
- Assists with quality reporting as needed.
- Routinely speaks at site, MSS, and/or provider meetings to educate and remind staff of documentation needed for successful gap closures.
- To connect people in need to the right services or support, to improve health and wellbeing outcomes in a timely and appropriate way.
- Identifying patient health and wellbeing needs.
- Locating and guiding to local resources that can help patients to achieve identified health goals.
- Enabling and empowering individuals to seek early intervention and prevention services.
- Supporting and assisting individuals to contact; access and engage with local services to meet their healthcare needs.
As a Transitions of Care Coordinator:
- Patient care activities
- Checks external health information systems (EPIC, Sunrise, etc) as well as the ADT folder, for Alcona Health Center patients, at assigned sites, with inpatient hospital discharges from the previous business day.
- Contacts patients with 48 business hours of recent inpatient discharge. Checks on patient status, reports and concerns to PCP. Reconciles post-discharge medications if able.
- Identifies patient/family education needs and ensures that patient/family members have adequate information to participate in transition planning.
- Advocates for patients and families within the health care system with community providers and across the continuum of care.
- Schedules patient with a follow-up visit with PCP with 7 or 14 calendar days depending on complexity.
- Thorough and timely documentation of all patient contact and attempted contacts (at least 2 in the 48 business hours post discharge).
- Communicates patient’s health status to provider to insure adequate provision of care, including referral to care manager if patient’s questions/concerns are outside of coordinators scope of practice.
- Patient Center Medical Home
- Pro-actively support PCMH initiatives related to care coordination.
- Pro-active member of care teams in team-based care initiatives.
- Partner with PCMH staff to develop integrated care management programs.
- Communication and Health Information Entered into Patient Record
- Enters appropriate treatment information into patient record in a timely fashion.
- Progress notes documentation is completed accurately, is written and maintained in a manner that is clear, complete, current, and organized in accordance with state and federal regulatory requirements.
- Continuously review charts for new and/or relevant information concerning clients.
- Communicates patient’s health status to provider to insure adequate provision of care.
- Evaluates complexity of patient's condition and determines appropriate level of care management, referring to an LPN care manager if available and appropriate.
- Routinely speaks at site, MSS, and provider meetings to remind staff of the services offered through Care Management and to encourage referrals from all staff.
Required Training & Experience:
- Possesses a current Basic Cardiac Life Support (BCLS) CPR
- Microsoft Office suite of products and use of Electronic Health Records system
- Possesses specific knowledge and training required to qualify as a Certified/Registered Medical Assistant, typically acquired through a Certified/Registered Medical Assistant trade school program. Requires in-depth understanding of medical assisting sufficient to effectively train or instruct others, or to serve as a resource to employees.
- Possesses a current State of Michigan driver’s license and valid automobile insurance.
We’re Here For You:
Supporting Balance: As a part of our family, you will work full time (40 hours/week) with a starting wage dependent on education and experience. Numerous holidays, generous vacation time and sick days are also offered.
Supporting Your Health: Low deductible Medical, Rx, Vision & Dental insurance at a minimal cost for employees (90% Employer Paid), as well as professional courtesy within our clinics.
Supporting Your Future: Retirement Savings Plan, FSA, Life, AD&D, & Short/Long Term Disability Insurance.
Supporting Your Education: Continuing Education Assistance program. Employment with AHC may also qualify you for student loan forgiveness under the Public Service Loan Forgiveness program.
Ready To Get Started?
Only applications through our Careers page at www.alconahealthcenters.org/careers/ will be accepted.
Resumes and cover letters are accepted and welcomed in addition to your completed application.
Questions can be sent to careers@alconahc.org
Fighting Against Discrimination:
Alcona Health Center is an Equal Opportunity Employer and Prohibits Discrimination and Harassment of Any Kind: Alcona Health Center is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment. All employment decisions at Alcona Health Center are based on business needs, job requirements and individual qualifications, without regard to race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. Alcona Health Center will not tolerate discrimination or harassment based on any of these characteristics. Alcona Health Center encourages applicants of all ages.
Upon request auxiliary aids and services will be made available to individuals with disabilities. Michigan Relay Center “Voice and TTY/TDD” 1-800-649-3777. An EOE.
Supporting Balance: As a part of our family, you will work full time (40 hours/week) with a starting wage dependent on education and experience. Numerous holidays, generous vacation time and sick days are also offered.
Supporting Your Health: Low deductible Medical, Rx, Vision & Dental insurance at a minimal cost for employees (90% Employer Paid), as well as professional courtesy within our clinics.
Supporting Your Future: Retirement Savings Plan, FSA, Life, AD&D, & Short/Long Term Disability Insurance.
Supporting Your Education: Continuing Education Assistance program. Employment with AHC may also qualify you for student loan forgiveness under the Public Service Loan Forgiveness program.
Ready To Get Started?
Only applications through our Careers page at www.alconahealthcenters.org/careers/ will be accepted.
Resumes and cover letters are accepted and welcomed in addition to your completed application.
Questions can be sent to careers@alconahc.org
Fighting Against Discrimination:
Alcona Health Center is an Equal Opportunity Employer and Prohibits Discrimination and Harassment of Any Kind: Alcona Health Center is committed to the principle of equal employment opportunity for all employees and to providing employees with a work environment free of discrimination and harassment. All employment decisions at Alcona Health Center are based on business needs, job requirements and individual qualifications, without regard to race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV Status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate. Alcona Health Center will not tolerate discrimination or harassment based on any of these characteristics. Alcona Health Center encourages applicants of all ages.
Upon request auxiliary aids and services will be made available to individuals with disabilities. Michigan Relay Center “Voice and TTY/TDD” 1-800-649-3777. An EOE.
