Care Coordinator

**Department**:Patient Centered Services

**Manager Title**:Care Coordination Manager

**FLSA Status**:Non-Exempt

**Job Purpose**:Responsible for coordinating care for specific populations of patients primarily at home site. Ensures referrals generated by PCC are completed by addressing barriers to care, increasing patient motivation, and establishing professional, dynamic relationships with patients, providers, referral sources, and other involved parties.

**Essential** Duties and Responsibilities**:

- Providers excellent customer service to internal and external customers
- Engages patients as active participants in their care
- Assists patients in scheduling and completing referrals as needed by coordinating between the patient, provider(s), and the referral source
- Establish relationships to coordinate patient referrals between patients provider and referral source to promote patient-centered services and ensure all reports are received by PCC
- Collaborate with providers, patients, AND AmeriCorps members to provide patients services needed for successful follow-up
- Advocate on patients behalf if needed to ensure completion of referrals
- Decrease barriers to care, increase motivation, and foster open communication
- Contact referral sources when reports/results are outstanding, request results/reports not automatically received by PCC
- Directs all reports to primary care provider.
- Notifies primary care provider of any incomplete/unsuccessful referrals
- Produce basic reports
- Achieve outcome-based metrics for performance
- Maximize services within care coordinator scope and refer to other staff as needed based on patients need and staff members position, licensure and scope of services
- Prepare data and documentation and have charts prepped for all applicable Case Management sessions
- Regularly attend and participate in monthly site team meetings
- Contribute to patient education materials and strategies to support care coordination
- Work with manager and team to create flow charts, workflows and document tracking process as needed
- Work with PI department to utilize computerized databases for tracking of identified high-risk areas by collecting, reviewing and inputting data into database and following up on all failed follow-up visits per program guidelines
- Follow guidelines to enhance care coordination for high-need, high-risk patients, tracking of high-risk areas as needed
- Develop supportive services and tools to address common barriers to care for PCC patients; integrate these with other initiatives for health promotion/education and access to care
- Performs other duties as required and assigned

**Experience/Training**:

- High school diploma required.
- Medical Assistant diploma from an accredited Medical Assistant program preferred.
- Certified or Registered Medical Assistant preferred.
- Associates or Bachelors degree preferred.
- Previous healthcare experience preferred
- Proficient in MS Office Business Application to include: Outlook, Word, PowerPoint and Excel

**P**h**ysical** Demands**:

- Must be able to remain in a stationary position 50% of the time.
- Must be able to move around the clinic site 50% of the time.
- Constantly operates a computer, computer printer, copy machine, and telephone.
- Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
- Must be able to transport from one site to another.
- Must be able to cover other shifts as necessary.
- Required shift rotation.

**Other Skills**:

- Ability to read and write proficiently using the English language.
- Constantly communicates with other healthcare providers. Must be able to exchange accurate information in these situations.
- Follow-through, assume responsibility and use good judgment.
- Maintain professionalism under stressful situations.
- Self-motivated and directed with the ability to prioritize and work efficiently under pressure.
- Ability to understand and follow verbal and written communication.
- Detail oriented with the ability to work with mínimal/no supervision.
- Willingness to be part of a team-unit and cooperate in the accomplishment of departmental goals and objectives.
- Effective and creative problem solving.