Care Coordinator - Population Health

at  SAC Health

WHO WE ARE:

SAC Health empowers our patients and their families to live vibrant and healthy lives through culturally responsive, exceptional care. Patient-centered, whole-person care. Our unique, full scope, team-based approach is what makes SAC Health the provider of choice for patients.
Top-Tier Patient Satisfaction Scores | Largest Teaching Health Center FQHC | 11 Locations offering 44 Specialties | NCQA Patient-Centered Medical Home Level 3 Certified Multi-Site Approved for NHSC & NCLRP loan forgiveness programs - NHSC/Nurse Corps/Pediatric Specialty | HPSA Scores: Primary: 17 | Dental: 25 | Mental: 20

QUALIFICATIONS:

• Education: High School Diploma or GED required. Graduation from a Certified Medical Assistant Program is required. Associate degree preferred, or equivalent work experience in a medical/mental health setting preferred.
• Licensure/Certification: Medical Assistant Diploma/Certificate is required. Valid California driver’s license, and auto insurance is required. As a requirement of this position, must complete and pass Epic training.
• Experience: 2+ years as a Medical Assistant in Care Management or Population Health setting or related experience is required.
• Essential Technical/Motor Skills: Must be proficient in MS Office Suite (Word, Excel, PowerPoint, Outlook). Must be able to use widely support internet browsers. Must have the ability to use variations of electronic health records and other various databases.
• Interpersonal Skills: Must have excellent communications skills both orally and in writing. Must possess the ability to communicate with and relate to a diverse group of people including patients, community, and other staff. Must have strong conflict and problem resolutions skills.
• Essential Mental Abilities: Must be flexible to perform a variety of tasks. Must be well organized and a self-starter. Must have strong analytical and problem-solving skills.
• Work Eligibility: Must be legally authorized to work in the United States on a full-time basis. Must not now or in the future require sponsorship for employment visas.
  EEO: SAC Health is committed to fostering a diverse, equitable and inclusive work environment and is committed to being an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

• Performs daily screenings using EMR-generated appointment reports and vitals for patients.
• Alert the provider of the need to place an order for an appropriate screening exam.
• Performs care coordination to ensure completion of provider-ordered screening exams. Uses relationship-based strategies to engage patients in care.
• Ensures that screening results are received timely and entered into the electronic medical record (EMR).
• Actively monitors results to ensure appropriate follow-up and diagnostic studies are ordered and completed, as appropriate. Assists patients to follow through on their care plan wellness goals, using both phone and in-person contact.
• Uses established care guidelines to implement provider-directed reminders and recalls in the EMR.
• Utilizes EMR-generated appointment reports to capture missed appointments. Assists in the coordination of appointments and referrals for physical and behavioral health appointments.
• Performs abstractions of historical screening results into the EMR system.
• Identifies internal and external challenges related to patient and staff cooperation.
• Recommends improvements to processes as appropriate.
• Meets with the Manage Care Team continually, holding documented meetings to review issues and progress.
• Serves as a liaison between patient and provider to ensure proper communication is had.
• Facilitates and ensures recommendations are communicated across the health care team. Works with patients to identify health/wellness goals and incorporates these goals into shared care plans.
• Maintains accurate and up-to-date tracking system for screening management.
• Monitors and reports productivity statistics, program status, challenges, updates, and developments to the Managed Care Team.
• Other duties as outlined in the official job description.