TCHP Care Coordinator - CBO TCHP Ambulatory Quality - Full Time - Days

The duties of this position involve care coordination for patients within the Primary Care Physician practice. The care coordinator works to implement and provide ongoing support of the care management program in collaboration with the primary care team. This will include supporting the primary clinical teams in monitoring health promotion, disease management and care coordination. The Care Coordinator will work with the Primary Care Physician, Care Manager and Practice Manager to best serve the needs of the patient and the primary care teams.

Care Management - Work with all clinical teams as a resource on care management

• Pre-visit planning workflow to ensure care completion prior to visit whenever possible

• Use of efficient, accurate point of care reminders for evidence based care

• After visit summary review with patients whenever appropriate

• Discuss with physicians and follow up appropriately to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by a specialty physicians, or by another health care provider;

• Involving the patients in activities to improve their health (patient engagement);

• Educating the patient about self-management tasks they can undertake to gain greater control of their health status.

• Facilitate referrals to other providers.

• Communicate regularly with patients to promote proactive health management

• Assist with scheduling follow up appointments, regular visits and referral appointments

Clinical quality and performance

• Works closely with providers as well as clinical staff to assure clinical quality is an ongoing priority in all phases of patient care

• Facilitates advanced management of care to an identified population.

• Coordinates patient care services for selected patients across the continuum of care through collaboration with the patient and family and health care providers in achieving optimal patient outcomes

• Participates in clinical quality activities and facilitate implementation of clinical best practices.

• Coordinate with physician leadership and RN Care Managers to develop strategies for the high risk patient population to coordinate patient care from office to hospital to home.

Provide the highest level of customer service to achieve the goal of “putting patient’s first”.

• Promote excellence in healthcare delivery to the patient and/or patient family. Identify and facilitate implementation of clinical best practices.

• Engages co-workers and patients in a positive, respectful manner

• Shows respect and sensitivity for differences among co-workers and patients

• Act as a point of contact to problem solve for the patient and clinical staff

• Conducts telephone calls backs to patients requiring follow-up care.

• Supports the clinical staff with health teaching and health counseling to patients and/or their families.

• Facilitate a seamless transition through the healthcare system

Information Technology

• Ensure complete and accurate documentation in the medical record.

• Design effective workflows using population management software, the electronic medical record and registries

• Collect and monitor data related to outcomes.

All other duties as assigned.

KNOWLEDGE AND SKILLS:

Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.

EDUCATION: High school graduate. Certification in a healthcare field such as a medical assistant or patient care assistant or college degree preferred..

YEARS OF EXPERIENCE: Minimum of 2 years experience as an MA, PCA or other related healthcare role.

REQUIRED SKILLS AND KNOWLEDGE:

Self motivated

Superior communication skills: Able to effectively communicate with others, both written and verbally

Possess critical thinking and problem solving skills

Abiltiy to prioritize work, and manage multiple demands

Knowledge of basic computer functions

Ability to work both with and for the team

Ability to show respect and sensitivity to cultural differences in both employees and patients

Knowledge and support of organization’s goals and values

Reliable and punctual

LICENSES & CERTIFICATIONS:

None