Patient Care Coordinator

Job Title: Patient Care Coordinator  

Company Overview:

Eau Claire Cooperative Health Center, Inc. (dba Cooperative Health) is a leading community health center serving the Midlands of South Carolina. It is deeply rooted in its mission of providing accessible, high quality, compassion health care in the spirit of the Good Samaritan. The organization’s values of: treating each other with respect, putting people first, being excellent at what we do, promoting a collaborative work environment, improving community/population health, fostering innovative thinkers, and getting results, are core attributes of every employee at Cooperative Health.

Description:

As part of the Cooperative’s care model of Patient Centered Medical Home (PCMH), the Patient Care Coordinator (PCC) shall promote quality health outcomes by exploring known or potential barriers to health improvement, addressing the social determinants of health that affect our communities and assuring that patient concerns are addressed in a timely manner. This role is responsible for patient orientation to available medical services in-house and locally; individualized follow-up of high-risk patients as per pre-determined vulnerability criteria and risk scores; and patient advocacy towards seamless implementation of interdisciplinary care plans and attainment of health goals.

The PCC will assist the clinical care team by engaging patients as partners responsible for their own health and well-being. This position will reach out to patients and families to support medical and psychosocial needs, foster self-management skills and behavioral change, and link patients to community resources/services. Finally, the PCC will support the mission, vision, and values of Cooperative Health, and work towards realizing its objectives through support of Clinical Operations and Clinical Quality.

Principal Responsibilities:

• Orients and educates patients and their families by meeting them; explaining the role of the patient care coordinator; addressing the care plan along with the care team as it relates to treatments, procedures, medications, and continuing of care requirements as outlined by the provider. Provide education to the patient in conjunction with the care team.
• Review provider schedules and individual patient charts and assist the care team in coordinating care for visits and for future healthcare needs.
• Provides an effective communication link between the patient and medical staff, including relaying messages from providers, gathering information from patients for providers, etc.
• Identifies patients to be case managed, assesses patient’s care requirements, modifies or coordinates modification of patient care and intervenes as necessary.
• Supports patient self-management of disease and behavior modification interventions.
• Coordinates continuity of patient care with external healthcare organizations and facilities, including the hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
• Manages high-risk patient care, including management of patients with multiple co-morbidities or high risk for readmission to a hospital setting.
• Evaluate the patient for social determinants of health that may impact their ability to meet the delivery of services goal. Social determinants can include: financial, geographic, transportation, linguistic, cultural, stress, employment/unemployment, job related issues to include work hours, work conditions; availability of healthy food/food insecurity, prior incarceration, religion, education, housing, social exclusion, social safety network, gender, health and medication literacy, race, and disability.
• Promotes clear communication amongst a care team and treating clinicians by ensuring awareness regarding patient care plans.
• Participates on a team for data collection, health outcomes reporting, clinical audits, and programmatic evaluation.
• Ensure that all patients are tracked and data entered into systems for follow-up and reporting.
• Regularly review EMR system information for an assigned panel of patients and arrange for care needed to proactively coordinate healthcare needs.
• Assists all support staff in daily patient interactions as needed.
• Monitor trends and implements strategies to assist patients with accessing appropriate levels of care.
• Engages patient and family to adhere to health care strategies aimed at improving quality of life through education, empowerment, and access to appropriate health care services.
• Ability to handle protected health information (PHI) in a manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Follows-up with patients, specialty providers, hospitals, and labs to obtain reports/discharge summaries as necessary.
• Provides patients with assistance in assessing eligibility for state/federal programs or refers to the appropriate agency/organization.
• Maintains a database of community and cultural resources and services and contact information (transportation, food banks, health education classes, etc.).
• Coordinates care among internal providers/programs (Ryan White/Behavioral Health/Oral Health) to assure the integration of services.

Education & Experience :

• Bachelor’s degree from an accredited school in Social Work, Public Health, Health Education or other related field OR
• Minimum of 3 years’ experience in a healthcare environment
• Preferred
• • Previous experience in a leadership/supervisory role
  • Teaching experience
  • Bilingual proficiency (English/Spanish)

Physical Demands

• Prolonged periods sitting or standing
• Must be able to lift up to 25 pounds.
• Be able to sit, stand, stoop, squat for extended periods of time throughout the day.
• Standing or walking for extended periods throughout the day.

Company Conformance Statement:

In the performance of their respective job assignments all employees are expected to conform to the following:

• Cooperative Health’s policies and procedures.
• Cooperative Health’s confidentiality and professional provisions
• Cooperative Health’s compliance program
• Cooperative Health’s standards of conduct

Cooperative Health provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Cooperative Health complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. 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.