Community Health Coordinator

Primary responsibility is to physically locate members/patients who are on payer defined rosters when other attempts to contact have been unsuccessful and/or contact information is not valid. Activities include being in the field to initiate contact by visiting home/places of last contact. Triggers for contact may be recent ED or IP discharge. When contact is made they develop relationships to engage the patient into the system and connect them to needed resources. Updated information is provided to the network for ongoing contact. Under the direction of clinical staff (care manager or care team), activities include outreach to patient's caretaker to connect them with providers/care team, close gaps in care, educate them on available community resources, and coach them on self-management of patient's care.

Minimum Education
B.S. (Required)

Minimum Work Experience
0 years No experience (Required)

Required Skills/Knowledge
Ability to motivate others towards achieving goals. Knowledge of community resources.
A strong sense of and respect for confidentiality involving both clients and fellow employees.
Ability to work in a variety of settings with culturally-diverse families and communities with the ability to be culturally sensitive and appropriate.
Ability to work independently with strong sense of focus, task-oriented, nonjudgmental, open personal qualities, clear sense of boundaries.
Good interpersonal, oral and written communication skills, ability to establish rapport.
Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point.
Spanish speaking preferred

Functional Accountabilities
Ambulatory Care Management Outreach

• Under the direction of clinical staff (care coordination or clinical practice), locates members when attempts to contact have failed and initiates contact by visiting home/places of last contact

• Initiates patient contacts in conjunction with the case management plan including patient contacts to close gaps of care and discharge follow-up and refers appropriate information to Care Manager

• Provides outreach and education to appropriate members and develops relationships to connect them to needed resources and applicable care management programs

• Under the direction of the Ambulatory Nurse Care Manager completes needs assessments, post-discharge questionnaires, care management screenings, and other clinical screening tools.

Collaboration with Medical Home and Care Management Team

• Under the direction of the Ambulatory Nurse Care Manager completes data collection, needs assessments, post-discharge questionnaires, care management screenings, and other clinical screening tools.

• Collaborates with clinical care team as well as care management care team to define role appropriate interventions to meet the patient's care management needs

• Interact and respond to inquiries from families, payers, external providers, and medical team by answering questions and explain information clearly and thoroughly.

• Informs care management team of any changes in patient location or status in a timely manner

Ambulatory Care Management Administrative Support

• Provides administrative support to the Medical Management team including answering phone queues and other general clerical functions

• Faxes information to external care providers (such as specialty pharmacies or home health agencies) under the direction of the care management team.

• Performs data entry and data retrieval activities as required.

Documentation and Data Management

• Documents patient consent for Care Management.

• Facilitate tracking/contact with patients who are:1 . on payer list but not actively followed,2 . OON and/or won't respond to practice,3 . declined care management intervention

• Documents patient contacts and interventions and files claims as directed by the care management team

• Maintains client and program records in accordance with applicable standards and payer requirements; identifies gaps in documentation and/or claims submission
• Maintains productivity standards for CM per department protocol
• Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

• Demonstrate collaborative and respectful behavior

• Partner with all team members to achieve goals

• Receptive to others' ideas and opinions

Performance Improvement/Problem-solving

• Contribute to a positive work environment

• Demonstrate flexibility and willingness to change

• Identify opportunities to improve clinical and administrative processes

• Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

• Use resources efficiently

• Search for less costly ways of doing things

Safety

• Speak up when team members appear to exhibit unsafe behavior or performance

• Continuously validate and verify information needed for decision making or documentation

• Stop in the face of uncertainty and takes time to resolve the situation

• Demonstrate accurate, clear and timely verbal and written communication

• Actively promote safety for patients, families, visitors and co-workers

• Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance