Clinical Care Coordinator

We’re different. In a good way. In communities like ours, co-workers and patients are our friends and neighbors. Sometimes they are family. And we take care of each other like family. If you’re tired of the typical workplace grind, we have something very different in store for you. Reasonable hours, a devoted team, a commitment to improvement, and believing in the value of every person – whether employee or patient – are just a few of the qualities for which we’re known. We’re a human potential company. Join us and experience the difference of the Desert Sage Way. We can’t wait to meet you.

Desert Sage Health Centers believes in patient-focused care delivered through a caring team of competent and caring health care professionals. As a Patient Centered Medical Home (PCMH), Desert Sage Health Centers prides itself in the quality of care it delivers to more than 7,800 annual patients at three health center site locations. Our integrated system emphasizes prevention, healthy living and is designed to reduce health care disparities and avoid unnecessary trips to emergency rooms or other more costly forms of care.

We are looking for an outgoing, compassionate, and hard working individual to join our Population Health team! If Desert Sage Health Centers and the Clinical Care Coordinator position seems like a good fit, then please take a few moments to submit your application!

Primary Duties And Responsbiliities

Clinical Care Management

• Serves as the organization’s key point of contact for initiating or delegating clinical response to patient needs identified through the Chronic Care Management Program, Remote Patient Monitoring, and similar services for patients
• Works with care teams and leadership to develop a prioritization list for building and managing care management panels
• Facilitates patient medication management based upon standing orders and protocols; includes conducting reconciliation for polypharmacy patients to ensure medication safety and patient understanding of medication use
• Facilitates health and disease patient education during clinic visits, virtually via telehealth encounters, telephone calls, and in the community during key Outreach activities
• Supports patient self-management of disease and behavior modification interventions
• Documents Remote Patient Monitoring and Care Management activities in the EMR to ensure proper documentation, maximum revenue capture, and relay important updates to primary care providers
• Works with internal programs such as Outreach, Behavioral Health, Dental, etc. to coordinate outreach, education, and appropriate services for care managed patients
  
  

Transitions of Care Support

• Continue to monitor and optimize mechanisms to reliably identify and track patients discharged from inpatient care; ensure patients discharged from the hospital are seen within 7-14 days of discharge
• Complete post-discharge calls to patients within 72 hours of discharge according to standard scripting (medication review, upcoming appointments, plan of care as outlined by hospital, etc.)
• Build a strong relationship with the hospital, and serve as the patient care liaison to ensure DSHC is able to receive notification and discharge information from the hospital(s) when patients are discharged and/or need follow-up appointments, leveraging health information exchange whenever possible
• Complete outreach to ensure high-risk patients receive appropriate screenings and services
• Connect patient to internal and external resources if needed, for example: Medication Assistance Programs, 340B, CHW, BH walk-in clinic, Women’s Health Check, Mammo Bus. Communicates closely with referral coordinators and updates Pop Health team regularly
• Other duties as assigned based on the needs of the health center
  
  

Minimum Qualifications

• Graduate of Medical Assistant program or accredited LPN program
• MA certification in good standing or State of Idaho LPN license in good standing
• Must hold current BLS card (healthcare provider)
• 3-5 years of direct experience providing case management to patient populations with varying backgrounds
• Demonstrated understanding of best practices in chronic disease case management and population health
• Demonstrated ability to act upon clinical data
• Demonstrated experience with running quality improvement projects and process improvements preferred
• Bilingual English/Spanish strongly preferred
  
  

Benefits include paid holidays, vacation, health and dental insurance. Salary is DOE.

If you are self motivated, compassionate and ready to give back to your community, and have the necessary training, come join our team!

Desert Sage Health Centers provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

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