Care Coordinator

2 weeks ago

New York, United States Care For The Homeless Full time

**Summary**:
The Care Coordinator position is integral to our integrated care team, dedicated to delivering exceptional care coordination services to our patients. This role is particularly focused on collaborating with and continuously supporting individuals who are chronically ill or considered "high-risk" patients. The Care Coordinator will establish and maintain effective partnerships with patients, their families, caregivers, and with specialty providers, clinics, hospitals, and other healthcare providers. Additionally, they will liaise with community resources to ensure a cohesive approach to healthcare, guaranteeing that all aspects of a care plan, including referrals and support systems, are seamlessly integrated.

Responsibilities include proactive outreach to patients, addressing care gaps, and managing instances of missed appointments. As a central point of contact for various health centers, the Care Coordinator will field calls, aiding patients in managing their appointments, responding to non-clinical inquiries, and directing callers to appropriate resources and personnel.

The role demands meticulous time management skills. The Care Coordinator is expected to independently manage their workload, implement effective tracking measures for patient care coordination, and adhere to strict deadlines to ensure timely access to healthcare services.

The Care Coordinator may also play a pivotal role in the development and implementation of on-site programs, collaborating closely with Population Health for the creation of promotional materials, site management, and provider engagement.

**ESSENTIAL DUTIES AND RESPONSIBILITIES**:

- Work directly with the referrals team to oversee the monitoring, tracking, and management of patient referrals, ensuring follow-through with recommended appointments.
- Support patients in attending specialized referral appointments, addressing potential barriers to ensure consistent care.
- Assist patients in managing their appointments at CFH Health Centers, including scheduling and cancellation, via telephone support.
- Provide internal referrals to other services within the organization, along with non-clinical community referral linkages, and monitor outcomes.
- Conduct targeted outreach to patients requiring follow-up care or screenings, leveraging phone communication to ensure timely healthcare interventions.
- Monitor patient compliance with scheduled medical appointments, proactively contacting those who have missed appointments or disengaged from care to reconnect them with necessary services.
- Facilitate connections for patients to community resources that support overall well-being, including sexual health programs, food assistance, legal services, etc.
- Engage with medical providers to discuss patients with high needs, coordinating outreach efforts and guiding patients to appropriate care pathways.
- Guarantee timely and appropriate care access for patients across various healthcare disciplines, advocating for patient needs, as necessary.
- Assist patients in navigating their insurance enrollment and management, including guiding them through the process of selecting or changing their Primary Care Provider (PCP) to ensure their insurance coverage aligns with their health and wellness goals.
- Demonstrate autonomy in executing job responsibilities, ensuring tasks are completed accurately and efficiently. This responsibility entails independently managing workloads, effectively implementing tracking measures for comprehensive patient care coordination, and adhering to stringent timelines to guarantee timely access to healthcare services.
- Contribute to the development and implementation of care transition protocols, enhancing patient care continuity.
- Serve as an active staff member in the CFH call center, efficiently screening calls, accurately routing messages to the appropriate resources, and providing information to CFH patients.
- Participate actively in Integrated Care Team huddles, team meetings, and interdisciplinary conferences to ensure cohesive patient care strategies.
- Perform additional tasks as required, supporting the organization's ongoing operations, including front desk support and scheduling assistance.

**JOB QUALIFICATIONS**:

- ** Education**:

- Bachelor’s Degree in Social Work, Public Health, or a related field preferred.
- **Experience**:

- 1-2 years of experience in care coordination, patient service, or patient outreach.
- Previous experience providing services and exercising leadership in a culturally and linguistically diverse setting, with demonstrated success.
- Prior experience in a health care setting, preferably FQHCs, strongly preferred.
- **Skill Sets**:

- Strong organizational skills: able to manage diverse responsibilities and provide services at various sites.
- Ability to establish and maintain effective working relationships with colleagues, patients, and contracted providers of health care services.
- Strong probl

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