Chronic Care Coordinator

2 months ago

Layton, United States Tanner Memorial Clinic Full time
Job DescriptionJob DescriptionDescription:

Tanner Clinic has an immediate opening for a Chronic Care Coordinator.


Location: Layton

Hours: FT


Essential Job Responsibilities:

  • Review patient data within population health tools and Electronic Health Record (HER) system to identify and enroll appropriate high-risk patients in care management services.
  • Work in partnership with primary care providers and each patient to establish a comprehensive goal-driven care plan.
  • Apply your clinical knowledge to address the patient’s chronic disease, psychosocial, behavioral health, hospital utilization, pharmaceutical, and social determinants of health barriers.
  • Coordinate care by serving as the advocate and resource for the patient, their family and their providers, building effective relationships in the community, (i.e., local hospitals, home health agencies, senior community services agencies, etc.) across the continuum of care to strengthen care coordination and safe care transitions across care settings.
  • Comply with billing requirements and the needs of each primary care practice when documenting care plans and care management services provided. Develop competency with various HER systems.
  • Leverage ACO methodology and care management toolkits to provide telephone-based support to patients enrolled in the chronic care management program, ensuring that patients are self-activated and achieving their healthcare goals, health outcomes and quality are improved and unnecessary utilization declines.
  • Identify and dis-enroll patients when goals have been achieved.
  • Liaise with ACO field team members and care management experts to ensure care management initiative aligns with other ACO initiatives and goals and care management barriers are addressed using a team-based approach.
  • Develop and deliver care manager training on population health tools, chronic care management guidelines, and effective care management techniques through regular conference calls and in-person training events.
  • Aid in the development of new or improved ACO systems, tools and workflows to ensure the needs of ACO Care Managers and patients are met efficiently.
  • Perform components of the Medicare Annual Wellness Visit as requested such as falls risk screening, depression screening, advance care planning, and other preventive services in the primary care provider office setting.
  • Participate in additional ACO activities within the practice as required.


Requirements:

Education:

  • MA or CNA preferred

Experience:

  • Medical Assistant with demonstrated skills and knowledge preferred.
  • At least 2-5 years of experience, preferably in case management, community public health, utilization management, or care coordination across multiple settings and with multiple providers
  • Knowledge of patient activation, motivational interviewing, chronic disease self-management, goal-driven care planning a plus
  • Excellent computer skills and willingness to learn new software applications. Electronic health record experience and population health management tool experience a plus
  • Familiarity with healthcare entities operating within the State
  • Experience providing care to vulnerable populations
  • Understanding of value-based healthcare, the ACO model, and population health fundamentals a plus
  • Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion
  • Strong work ethic built on a foundation of productivity, collaboration and teamwork
  • Ability to manage multiple projects and activities with minimal supervision
  • Demonstrated knowledge of continuous quality improvement techniques


Performance Requirements:


Knowledge:

  • Clinical Knowledge: Demonstrated understanding of chronic diseases, psychosocial aspects, behavioral health, hospital utilization, pharmaceuticals, and social determinants of health.
  • Population Health Management: Proficient in using population health tools and Electronic Health Record (EHR) systems for reviewing patient data and identifying high-risk individuals.
  • Care Coordination: In-depth knowledge of care coordination principles, including building effective relationships in the community, coordinating care transitions, and serving as an advocate and resource for patients and their families.
  • ACO Methodology: Familiarity with Accountable Care Organization (ACO) methodology and care management toolkits to provide effective telephone-based support to enrolled patients.
  • Medicare Annual Wellness Visit: Competency in performing components of the Medicare Annual Wellness Visit, including falls risk screening, depression screening, advance care planning, and other preventive services.

Skills:

  • Communication: Exceptional written and oral communication skills, with the ability to positively influence others with respect and compassion.
  • Computer Proficiency: Excellent computer skills with the ability and willingness to learn new software applications, including electronic health record systems and population health management tools.
  • Training and Education: Ability to develop and deliver training on population health tools, chronic care management guidelines, and effective care management techniques through various formats, including conference calls and in-person events.
  • Teamwork: Strong work ethic focused on productivity, collaboration, and teamwork, particularly in liaising with ACO field team members and care management experts.
  • Project Management: Ability to manage multiple projects and activities with minimal supervision, ensuring efficient and effective care coordination.

Abilities:

  • Patient-Centered Approach: Apply clinical knowledge to address the holistic needs of patients, including chronic disease management, psychosocial support, and goal-driven care planning.
  • Problem Solving: Demonstrate the ability to identify and address care management barriers, align care management initiatives with ACO goals, and contribute to the development of new or improved ACO systems and workflows.
  • Continuous Quality Improvement: Utilize demonstrated knowledge of continuous quality improvement techniques to enhance care management services.
  • Adaptability: Willingness to adapt to changes in healthcare systems, software applications, and care delivery models, ensuring the needs of ACO Care Managers and patients are met efficiently.


Equipment Operated:

  • Standard office equipment (e.g., computer, phone)
  • Electronic Health Record (EHR) systems


Work Environment: Office environment


Mental/Physical Requirements:

Sitting and computer work 90% of the day.



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