Primary Care Medical Office
2 weeks ago
Striving for a Healthier Community
Excel Medical Center LLC is seeking a full-time Value-based Care Coordinator to join our team.
Be a part of meaningful work by providing support to patients seeking quality healthcare while working with a diverse underserved patient population.
Excellent opportunity to have a positive impact on our patient's health while working with Providers and patients.
Who are we?...
Excel Medical Center LLC is a growing primary care practice with a mission to serve the medically-underserved adult, urban population located in the Philadelphia area via our 15 primary care clinical locations.
In addition, we provide medical management in 13 Nursing Homes/Long-Term Care (LTC) setting.
We are actively seeking a positive, caring, experienced Care Coordinator with a strong Social Worker experience set, to be based in one of our North Philadelphia primary care clinics.
This position is responsible for providing care coordination for Value-based (VB) care gaps with Medicare Advantage (MA) patients and/or Dual Eligible Special Needs Plan (DSNP)
The Care Coordinator leverages their strong social worker skills to create a caring, positive experience for patients by building trusted relationships over time. This includes helping patients access the right care at the right time with their health plan, as well as access to providers, pharmacies, other vendors, and community-based organizations. Examples include scheduling Annual/Well visits, addressing gaps in care, scheduling PCP appointments for Hospital ER follow-up.
The Care Coordinator assesses and works with patients to address both their medical needs and their social needs, as expressed via the factors of Social Determinants of Health (SDOH) criteria.
In this visible role, Care Coordinators,
- Conduct outreach to motivate, facilitate, and educate patients about the benefits of various programs.
- Conduct assessments of the patient's status and develop a care plan with the patients to address their goals.
- Assessments are conducted by telephone and/or text and may be conducted in person.
- Facilitate coordination of care with providers and schedule patient's appointment as needed.
- Motivate patients to be active and engaged participants in their own health, healthcare and overall well-being.
- Identify and help address needs related to Social Determinants of Health (SDOH).
- Coordinate and complete correspondence according to established workflows.
- Thoroughly and accurately document actions taken in a care management platform.
- Make a high volume of outreaches to patients, families, providers, or other recipients as needed to successfully perform the role.
To be successful in this position, must have the following skills and abilities:
- Excellent interpersonal and communication skills
- Patient, caring approach to help patients navigate to best care pathways.
- Ability to work in a fast-paced environment.
- Strong Quality and results-orientation
- Demonstrated strong written and verbal communication skills
- Tech enabled - have verified experience documenting case notes in a care management or electronic health records management (ERM) platform
- Strong problem-solving capability (conceptual thinking/ analytical thinking skills)
- Excellent organizational and multi-tasking skills
- Demonstrated attention to accuracy & details when documenting case notes
- Understands and prior experience with continuous process improvement
- Demonstrated experience with motivational patient interviewing
- Excellent work ethic
- High degree of initiative and works well as a team player
and demonstrated ability to:
- Work is motivated by a strong mission-orientation to serve urban, adults in medically underserved areas (MUAs)
- Demonstrated passion for helping people improve their lives through better health.
- Work effectively with a wide range of diverse, patient populations in an urban community, while demonstrating cultural competencies necessary to navigate complex situations.
- Open-minded toward continual learning of the diverse patient's cultures and values.
- Be an advocate for, support, and motivate patients to manage their health and healthcare.
- Maintain positive working relationships with patients and their families, providers, and other external partners.
- Build trust, actively listen, intentionally communicate, collaborate, and problem-solve.
- Influence others toward positive outcomes.
Background and Experience Required:
- A bachelor's degree (BA/BS) in Social Work; MSW is a +.
- Practical, hands-on experience in a medical-related field providing patients with social work services, health education, etc.
- Minimum 1 year prior experience working in primary care physician practice setting.
- Minimum 2+ years' relevant experience as a primary Value-based care gaprs/care practice coordinator, case manager, community health worker, or social worker serving a case load of patients.
- Minimum 2+ year prior experience working with a medical EMR; AthenaOne is a plus +
- Minimum 1 year prior experience working with insurers and associated insurer/payer portal systems (HealthTrio is a plus +)
- Min 1+ year experience working with Medicare Advantage and/or Dual Eligible patients.
- Language fluency to speak/translate Spanish or Haitian Creole is a plus (+)
Excel Medical Center ~ OUR MISSION
Excel Medical Center strives to heal, educate and care for the community. We excel in providing adults with high quality, evidence based and preventive medicine.
We strive for a healthier community by making our clients' healthcare needs our focus and concerns.
We believe in a strong, positive and enduring partnership with our clients in managing their healthcare needs.
Primary Care
As primary care physicians we are available to provide day-to-day health care. We enthusiastically assume responsibility as our patient's first contact and principal point of continuing care. We coordinate with specialist care facilities and hospitals that we trust to provide ideal specialized care to further assess and better assist.
Behavioral Healthcare (BHI)
We understand the real life challenges our patients face living in urban setting. We have integrated our Behavioral Health treatment into our Primary Care practice to help our patients chart a course of action beyond addiction and mental/behavioral health conditions.
Preventative Care
Our preventive healthcare consists of steps taken for disease prevention. We provide these services on the basis that getting preventive care, such as screenings and immunizations, can help you and your family stay healthy.
Focus on Wellness:
We create an atmosphere that invites our adult patients to visit us, as their health care provider, from time to time, healthy or otherwise. The purpose of these visits is to:
Screen for diseases, such as high blood pressure and diabetes
Search for potential disease risks, such as high cholesterol and obesity
Counseling on such topics as quitting smoking, losing weight, eating healthy and reducing alcohol use
Flu and pneumonia shots
STD screening
Excel Medical Center LLC is an Equal Opportunity Employer
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