QUALIFICATIONS

• RN, RT or Licensed Social Worker with three to five years’ experience.
• BSN preferred
• CCM (Certified Care Manager) preferred
• Current, active, and unrestricted certification/license
• Demonstrated skills in leadership, advocacy, communication, education, and counseling.
• Culturally effective capabilities demonstrating a sensitivity and responsiveness to varying cultural characteristics and beliefs.

KNOWLEDGE AND SKILL REQUIREMENTS:

• Self-motivated, dependable, strong work ethic with a desire to learn.
• Strong time and project management skills.
• Ability to work effectively in a team environment.
• Experience with computer applications.
• Ability to apply critical thinking skills and make sound judgments both while performing daily responsibilities and throughout the patient’s continuum of care.
• Knowledge of the case management process and the patient-centered medical home (PCMH).
• Knowledge and demonstrated abilities to work in a regulatory climate that includes oversight by federal and state rules, payer contracts, governmental benefits, and community resources.
• Effective oral and written communication skills.
• Excellent interpersonal skills reflecting clarity and diplomacy and the ability to communicate accurately and effectively with all levels of staff and management.
• Detail-oriented, thorough, and able to handle multiple tasks and projects with varying deadlines and priorities.
• Ability to interpret and relay to patients (and their caregivers) the applicable Medicare, Medicaid, or private insurance coverage for ordered services to include information about coverage limits and any costs the patient may incur.
• Ability to work successfully in a fast-paced, stressful environment.
• Ability to work with a registry and an electronic health record.
• Empathy, mental alertness, precision, analytical problem-solving abilities, communication skills, focus, and initiative.
• Fundamental knowledge of healthcare organization, operations, and processes.

GENERAL SUMMARY OF DUTIES:

The Care Coordinator supports the practice by working with patients, families, providers, and staff to promote timely access to needed care, providing daily continuity of care coordination, and coaching patients, families, and caregivers to understand the patient’s care plan and self-care management responsibilities.

ROLE AND RESPONSIBILITIES:

• Use case management processes to assure quality care is delivered to the PHC’s patients, the patients’ families, and the patients’ caregivers in the most efficient and effective manner across the healthcare continuum.
• Apply the principles of comprehensive, community-based, patient-centered, developmentally appropriate, and culturally and linguistically appropriate care coordination.
• Engage patients, patients’ families, and their caregivers in understanding, setting, and monitoring patient self-management care plans in a manner that is culturally and linguistically appropriate to the patient and caregiver.
• Document each patient’s individualized care plan and care coordination in PHC’s EHR.
• Coordinate the patient’s care by facilitating patient, family, or other caregiver access to medical home providers, staff, and resources as needed by the patient.
• Conduct and document assessments of patient needs and resources for effective self-care management.
• Develop and maintain relationships among patients, patients’ families, and the patients’ care team that support patients’ access to the medical home.
• Act as the primary contact point, advocate, and source of information for patients and the community partners who help treat them.
• Research, find, and link patients to resources, services, and support mechanisms for their care plans and self-care management needs.
• Provide timely communication with patients, make inquiries, execute follow-up actions, and help to integrate information into the care plan.
• Assist the care team by helping to measure quality and identify, refine, and implement performance improvements that support the medical home.
• Assist the care team in performance evaluation and quality improvement.
• Continually monitor the cost effectiveness of services provided through the patient’s individualized care plans, and recommend any needed changes to those plans based on evidence-based, clinical guidelines from sources identified by the Practice.
• Participate in continuing professional growth through attendance at workshops and professional in-services and through individual research and reading, to include communication skills.
• Participate in population management activities as directed by PHC.
• Attend and participate in organized functions of PHC and perform administrative functions as necessary.
• Demonstrate personal responsibility and respect for patients, patients’ families, and coworkers in professional appearance.
• Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams.
• Others duties as assigned