Care Coordinator

GENERAL PURPOSE:

Under the supervision of the Care Coordination Nursing Supervisor, this position is responsible for providing care coordination to high-risk patients at Ampla Health. Care Coordinators are responsible for getting patients in to see their primary care physician within 3-7 days of hospital discharge, providing health education and supporting patients in establishing and achieving care and treatment goals.

MAIN RESPONSIBILITIES AND DUTIES:

• Maintains at a minimum a caseload of at least 150 high-risk patients who were admitted or discharged from the ED or hospital.
• Conducts daily outreach to assigned panel of patients within 1-2 business days of notification to Ampla Health of patient hospital discharge.
• Actively enrolls all eligible patients into the Transitions of Care Program.
• Secures patient discharge instructions and uploads to patient chart.
• Uses the Ideal Transitions of Care Framework for coordinating care for high risk patients.
• Provides medication adherence support through facilitation, patient education, and service linkages.
• Performs quality control for post discharge medication reconciliation by PCP.
• Conducts patient assessments including but not limited to chronic disease and social needs screenings.
• Assists patients in securing medications, understanding instructions, securing appointments, and accessing a variety of clinical and social support services.
• Assists patients in establishing and achieving care and treatment goals through a documented care plan.
• Coordinates with Ampla primary care and other departments to achieve patient centered care and optimize patient communication and care.
• Assists with referring patients to the Chronic Care Phamily Program
• Maintains an accurate record of outreach, communications, patient needs, and services.
• Works to achieve TOC program metrics as detailed to Table 1, below.
• Supports Ampla Healths mission by providing superior customer service and respecting patients.
• Strengthens clinical and quality team work and rapport through strong work ethic and individual accountability.
• Maintains professional growth by attending trainings, staff meetings, and required in-services as necessary.
• Treats patients with empathy and respect and conduct oneself in a professional manner.
• Complies with organizational guidelines and health care laws and regulations.
• Other duties as assigned by supervisor.

TABLE 1: AMPLA HEALTH TRANSITIONS OF CARE PROGRAM METRICS

QUALITIES & CHARACTERISTICS

• Maintains a professional relationship and positives attitude with co-workers, the public, patients and all Ampla Healths staff, Board of Directors and vendors
• Maintains the highest professional ethics and is honest in dealing with people; is a model for all employees through their actions
• Strives to learn more and is receptive to learning different ways of doing things
• Displays enthusiasm toward the work and the mission of Ampla Health
• Ability to work in a fast-paced, patient service-oriented environment

PROFESSIONAL KNOWLEDGE, SKILLS & ABILITIES:

• High School Diploma
• Completion of Medical Assistant
• Strong problem solver
• Possesses outstanding interpersonal skills, including excellent written and verbal skills
• Ability to connect and engage patients in person and over the phone
• Demonstrates ability to promote quality improvement through development and maintenance of standards
• Sensitive to the needs of the cultures represented in the Ampla Health patient population
• Demonstrates clear knowledge of Ampla Healths clinic structure, standards, procedures, and protocols

COMMUNICATIONS SKILLS:

• Must have neat and legible handwriting
• Must be able to interact with patients courteously and calmly
• Ability to communicate well with the public

WORKING CONDITIONS & PHYSICAL REQUIREMENTS:

Works will with patients in a generally comfortable environment office. Employees must possess the following physical requirements:

• Must be in good health and able to lift up to 40 lbs
• Must be able to hear staff on the telephone and those who are served in person, and speak clearly to communicate information to clients and staff
• Ability to operate standard office equipment such as a computer, telephone, fax machine, copier, etc.
• Must be able to reach above the shoulder level to work, bend, squat and sit, stand, stoop, crouch, reach, kneel, twist and turning

GENERAL PURPOSE:

Under the supervision of the Care Coordination Nursing Supervisor, this position is responsible for providing care coordination to high-risk patients at Ampla Health. Care Coordinators are responsible for getting patients in to see their primary care physician within 3-7 days of hospital discharge, providing health education and supporting patients in establishing and achieving care and treatment goals.

MAIN RESPONSIBILITIES AND DUTIES:

• Maintains at a minimum a caseload of at least 150 high-risk patients who were admitted or discharged from the ED or hospital.
• Conducts daily outreach to assigned panel of patients within 1-2 business days of notification to Ampla Health of patient hospital discharge.
• Actively enrolls all eligible patients into the Transitions of Care Program.
• Secures patient discharge instructions and uploads to patient chart.
• Uses the Ideal Transitions of Care Framework for coordinating care for high risk patients.
• Provides medication adherence support through facilitation, patient education, and service linkages.
• Performs quality control for post discharge medication reconciliation by PCP.
• Conducts patient assessments including but not limited to chronic disease and social needs screenings.
• Assists patients in securing medications, understanding instructions, securing appointments, and accessing a variety of clinical and social support services.
• Assists patients in establishing and achieving care and treatment goals through a documented care plan.
• Coordinates with Ampla primary care and other departments to achieve patient centered care and optimize patient communication and care.
• Assists with referring patients to the Chronic Care Phamily Program
• Maintains an accurate record of outreach, communications, patient needs, and services.
• Works to achieve TOC program metrics as detailed to Table 1, below.
• Supports Ampla Healths mission by providing superior customer service and respecting patients.
• Strengthens clinical and quality team work and rapport through strong work ethic and individual accountability.
• Maintains professional growth by attending trainings, staff meetings, and required in-services as necessary.
• Treats patients with empathy and respect and conduct oneself in a professional manner.
• Complies with organizational guidelines and health care laws and regulations.
• Other duties as assigned by supervisor.

TABLE 1: AMPLA HEALTH TRANSITIONS OF CARE PROGRAM METRICS

QUALITIES & CHARACTERISTICS

• Maintains a professional relationship and positives attitude with co-workers, the public, patients and all Ampla Healths staff, Board of Directors and vendors
• Maintains the highest professional ethics and is honest in dealing with people; is a model for all employees through their actions
• Strives to learn more and is receptive to learning different ways of doing things
• Displays enthusiasm toward the work and the mission of Ampla Health
• Ability to work in a fast-paced, patient service-oriented environment

PROFESSIONAL KNOWLEDGE, SKILLS & ABILITIES:

• High School Diploma
• Completion of Medical Assistant
• Strong problem solver
• Possesses outstanding interpersonal skills, including excellent written and verbal skills
• Ability to connect and engage patients in person and over the phone
• Demonstrates ability to promote quality improvement through development and maintenance of standards
• Sensitive to the needs of the cultures represented in the Ampla Health patient population
• Demonstrates clear knowledge of Ampla Healths clinic structure, standards, procedures, and protocols

COMMUNICATIONS SKILLS:

• Must have neat and legible handwriting
• Must be able to interact with patients courteously and calmly
• Ability to communicate well with the public

WORKING CONDITIONS & PHYSICAL REQUIREMENTS:

Works will with patients in a generally comfortable environment office. Employees must possess the following physical requirements:

• Must be in good health and able to lift up to 40 lbs
• Must be able to hear staff on the telephone and those who are served in person, and speak clearly to communicate information to clients and staff
• Ability to operate standard office equipment such as a computer, telephone, fax machine, copier, etc.
• Must be able to reach above the shoulder level to work, bend, squat and sit, stand, stoop, crouch, reach, kneel, twist and turning