Integrated Care Coordinator

Summary Of Position

The Integrated Care Coordinator supports a team-based care delivery model within a Patient-Centered Medical Home (PCMH) in a Federally Qualified Health Center (FQHC). This role is essential in facilitating seamless patient care across the continuum, enhancing access to resources, and closing care gaps. The ideal candidate, a Medical Assistant or Community Health Worker, will work collaboratively with an integrated care team to perform pre-visit planning, post-visit follow-ups, and patient-centered interventions that promote continuity and quality of care.

Essential Job Results

Key Responsibilities

• Pre-Visit Planning
• Prepare for patient visits by reviewing care plans, any outstanding orders, recent tests, referrals, and any outstanding care gaps.
• Coordinate with care team members to ensure all necessary documentation, labs, and screenings are completed before the visit.
• Identify and address barriers to care, including transportation, scheduling conflicts, and health literacy needs.
• Conduct the necessary proactive outreach to the patient to support the completion of any outstanding orders, close any outstanding care gaps (through the utilization of standing orders as appropriate), and assist in reducing or removing any medical or non-medical barriers to care as appropriate.
• Communicate with care team members to ensure patient care is well coordinated, organized, and the team is adequately prepared for upcoming visits.
• Post-Visit Follow-Up
• Conduct follow-up outreach to patients after appointments to check patient status, review medication instructions, and identify any challenges or barriers the patient may be experiencing in following the plan of care.
• Monitor and document patient progress, addressing concerns or connecting them to additional resources, services, or programs within the health center as needed.
• Care Coordination and Linkages
• Organize and facilitate activities of care across the continuum, create linkages to care and connection to external community resources and/or programs as needed.
• Assist in the building and/or maintaining of relationships with community organizations to enhance patient access to resources that address risk factors and/or social determinants of health (ie: food, housing, transportation, or financial assistance).
• Serve as a liaison between patients and care team members, ensuring open communication and collaboration.
• Patient Outreach and Patient Engagement
• Conduct outreach to engage patients in essential services such as preventive care, chronic disease management, and health education.
• Provide culturally competent outreach and appropriate education to patients and families to empower them to engage as active participants in their health.
• Assist in closing care gaps by conducting outreach to inform and/or remind patients of needed screenings, immunizations, and follow-ups. Assist with the scheduling of services as appropriate.
• Team-Based Collaboration
• Work closely with medical assistants, referral coordinators, care managers, nurses, providers, and other integrated care team members to ensure well organized, highly coordinated, patient-centered care.
• Participate in team huddles and meetings to discuss patient needs, share updates, and address barriers to care.
• Support quality improvement initiatives by identifying opportunities to enhance care delivery and patient outcomes.
• Referrals are to be tracked in accordance with our policy and procedures with status documented to completion.
• Documentation and Reporting
• Accurately document all patient interactions, interventions, and outcomes in the electronic health record (EHR).
• Track and report on key metrics related to patient engagement, care coordination, and quality improvement.
  
  

Carries out Vibrant Health’s mission.

Accepts and uses supervision, direction and consultation to maximize available resources in the completion of work duties.

Additional responsibilities will be assigned as needed to maintain and improve effective functioning of the department and to advance the mission of the organization.

All job responsibilities will be carried out under the direction of the organization’s policies and procedures.

Required Knowledge, Skills, And Abilities

• Medical Assistant certification or Community Health Worker (CHW) Certification.
• Previous experience in a team-based care model, PCMH, or FQHC setting is highly desirable.
• Proficiency in use of personal computers and Microsoft Office Suite (Word & Excel) required
  
  

Individual Must Have

• Strong interpersonal and communication skills with the ability to build trust with diverse populations.
• Knowledge of care coordination, chronic disease management, and community resources.
• Proficiency in electronic health records (EHR) and patient management systems.
• Excellent organizational skills and the ability to manage multiple tasks in a dynamic environment.
• Develop rapport with patients and their families, community and other health care personnel.
• Must exhibit a professional and respectful demeanor.
• Work successfully within team environment and collaborate with other professional staff.
• Demonstrate excellent customer service, helpfulness, and a positive attitude.
• Demonstrate the ability to recognize, understand, and appreciate the value of cultural diversity. Demonstrate social and cultural sensitivity appropriate to ethnically and economically diverse patients and staff.
• Travel to all parts of the facility and throughout the community.
  
  

PREFERRED KNOWLEDGE, SKILLS, AND ABILITIES

Bilingual English and Spanish (preferred but not required based on patient population).

Americans with Disability Specifications

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands and fingers to handle or feel objects, tools or controls; reach with hands and arms; climb stairs; talk and hear. The employee must frequently lift and/or move materials that may weigh up to 40 pounds.

Work Environment

Work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must have manual dexterity and experience to perform handwritten paper work, recordkeeping, and filing.
• Prolonged sitting, standing, or walking may be required.
• Frequent bending/stooping, squatting, reaching above the shoulders, twisting and turning, kneeling, and pushing/pulling may be required.
• Employment is contingent upon successful clearance from Criminal, Kansas and Missouri Child/Elder Abuse and Neglect, Sex Offender background investigations, TB testing, pre-employment drug testing, and verification of Hepatitis-B immunization.
• Occasional evening and weekend availability is required.
  
  

Commitment to Diversity

We are proud to be an Equal Employment Opportunity (EEO) and Vietnam Era Veterans Readjustment Assistance Act (VEVRAA) Employer. We are committed to cultivating a workplace in which diverse perspectives and experiences are welcomed and respected. We do not discriminate on the basis of race, color, religion, creed, ancestry, national origin, sex, age, disability (physical or mental), marital or veteran status, genetic information, sexual orientation, gender identity, political ideology, or membership in any other legally protected class. We are an Affirmative Action employer. We encourage individuals with diverse backgrounds to apply and desire priority referrals of protected veterans