Clinical Care Coordinator, Ambulatory

4 weeks ago


Springfield VT, United States Springfield Medical Care Systems, Inc. Full time

North Star Health, an independent Federally Qualified Health Center comprised of multiple PCMH practices delivering team-based care in Southern VT and Southwestern New Hampshire, is seeking Clinical Care Coordinator at our Springfield Health Center. In this pivotal role, you will engage individuals seeking to prevent and manage chronic conditions, identify their priorities for their care, develop a care plan and coordinate its implementation in partnership with the patient, their care team and community partners.
Promote and work to achieve our mission and vision to connect with and care for our community so everyone may enjoy health and wellness.
* Assess patient's clinical, social, functional and continuing care needs to identify their priorities and the desired outcomes for their treatment.
* In consultation with the patient, their care team and related partners, develop a care plan including immediate, short term, and long-term goals reflecting patient's priorities and time frames to achieve desired outcomes.
* Demonstrate knowledge and understanding of the client's diagnosis, prognosis, care needs, as well as cost and barriers to goal achievement.
* Assist in transition of care though patient outreach, communication with relevant service providers following discharge from other care settings to ensure a smooth transition to outpatient care, with the goal of decreasing readmissions.
* coordinate with other team members to provide exceptional patient service.
* Maintain positive working relationships and demonstrate exceptional customer service skills. Facilitate patient access to appropriate medical and specialty providers as well as other care coordination team support
* Serve as a point of contact, advocate, and informational resource for patient, family, care team, payers, and community resources and facilitate and attend meetings between patient, families, care team, payers, and community resources, as needed
* Proactively outreaches to selected patients, perform home visits as necessary for assessment and engagement
* Participates in quality improvement activities, collecting and analyzing data
Experience with Care Planning
* Two (2) year's nursing experience
* Proficiency with Microsoft Office, computer skills
* Interested candidates should provide a cover letter addressing the scope of the role , in addition to completing the application.
All new hires are required to show proof of COVID vaccination or request an exemption prior to starting work.



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