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Clinical Care Coordinator
4 weeks ago
Summary
Collaborate with providers to create, manage and maintain patient care plans, including self-management activities, leveraging the appropriate care management resources from Marathon Health services, the health plan, the community, and other employer-based resources.
Essential Duties and Responsibilities
- Determination of the necessity for patient outreach based on pre-selected criteria.
- Engage identified members through internal portal or other secure communications method.
- Address Transitions of Care (TOC), recent ER visits and complex care patients.
- Discuss gaps in care and care opportunities.
- Discuss the need for enrollment in a Care Management or Health Coaching Program for a chronic care condition(s).
- Discuss medication reconciliation and adherence.
- Engage and promote self-management activities and resources.
- Help patients obtain discounts on medications that they cannot afford, or work with provider to find a more affordable option.
- Educate patients on disease processes and medications, side effects, provide available literature and medical documents, and explain treatment procedures as directed by provider. Provide patient education and resources for their TOC, chronic care condition(s), and/or barrier(s) to care.
- Collaborate with clinic staff, health coach, data and referrals team to support patient on their wellness journey.
- Encourage/support, clinical goal setting (i.e.A1c target), self-management and wellness.
- Assess patient's emotional well-being and social needs.
- Identify barriers to care for each individual and follow through with a variety of options for success in health and wellness objectives.
- Coordinate referrals, schedule exams, procedures, and appointments for patient.
- Utilize knowledge of community resources such as housing, food, transportation, and childcare to assist patient in achieving goals.
- Review EMR information and document member-outcomes. Flag gaps in care and key details in the patient' charts or EMR.
- Assist with medical physical forms, fitness for duty forms, and absence management for medical conditions (short term disability, long term disability, FMLA, etc.).
- Refer to and use available provider, health coaching, referral, and health plan and community resources.
- For those individuals with an existing specialist or previous specialty care, and in particular for those individuals who have multiple complicated medical conditions requiring specialty care and/or significant oversight, the clinician will work in collaboration with said provider to provide adjunct care and education to the member.
- Support to ensure care plans for all specialists are consolidated in the Marathon EMR and the provider team is knowledgeable about the member's care needs and efforts outside of the Marathon Health care team.
- Maintain a sense of urgency and excellent response times for same day referrals that are urgent in nature (not handled by MRT).
- Research and maintain up-to-date knowledge of the client's current benefits programs for member assistance.
- Assist members to understand their available employer benefits solutions as appropriate.
- May perform some general office administration including welcoming patients, answering phones and voice mail, scheduling appointments, handling correspondence and confidential files, office and medical literature and brochures, managing signage and bulletin boards, and ensure presentation is professional in appearance, up-to-date, and according to Marathon Health branding standards.
- Comply strictly with medical care regulations and safety standards. Follows HIPAA guidelines for patient confidentiality.
- Research the latest treatments, innovations, advances, and trends in the medical industry.
- Must maintain continuing education to maintain medical license and certification status.
- Bachelor's Degree in Nursing or related field of study
- Current Registered Nurse Certification and active license required, Phlebotomy Certification, and CPR/BLS certifications.
- 4+ years of experience as a registered nurse.
- Experience as a care manager is strongly preferred.
- Experience in a collaborative care model
- Strong connections to the local community and available resources
- Passion for wellness and ability to navigate healthcare systems
- Working knowledge of medical terminology, basic lab interpretation, practical nursing theories and policies
- Knowledge of Privacy Act and HIPAA Privacy Rule standards to maintain compliance, and to secure and protect medical and other protected health information.
- Strong technical expertise using an Emergency Medical Record (EMR) system, Microsoft Teams and Microsoft 365 including Word, Excel, Outlook, PowerPoint, etc. Proficiency in Athena preferred.
- Excellent written and oral communications skills. Ability to communicate medical conversations with clients, patients, business leaders and professionals.
- Exceptional customer service skills and ability to promote teamwork. Ability to build and maintain trusting relationships by approaching all work with integrity and commitment.
- Excellent time management skills and ability to multi-task, prioritize work, execute a plan, and meet deadlines.
- Flexibility and adaptive skills with the ability to effectively manage competing priorities in a constantly evolving workplace in a fast-paced environment.
- A proven record of successfully working with employees, stakeholders, clients, vendors, and guests.
- Excellent organizational skills and meticulous attention to detail.
- High level of critical thinking, and creative and effective problem-solving skills.
- Ability to maintain confidential documents and communication and use judgment and discretion.
The actual offer may vary dependent upon geographic location and the candidate's years of experience and/or skill level.
We are accepting applications for this position until a candidate has been selected. To apply to this position and learn more about open jobs at Marathon Health, visit our careers page.
Marathon Benefits Summary
We believe in empowering teammates to do their best work and build better healthcare. Below are some of our benefit offerings. Eligibility is based on 24/hr week.
Health and Well-Being: Free Marathon membership for in person and virtual care, employer paid life and disability insurance, and choice in medical/dental plans, vision, employer funded HSA, FSA, and voluntary illness, accident and hospitalization plans. Benefits are effective on the first of the month following date of hire.
Financial Support: Competitive compensation, 401k match, access to financial coaching through our Employee Assistance Program
Lifestyle: Paid time off for vacation, sick leave, and more, holiday schedule
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