Ambulatory Care Coordinator

The Care Coordinator's primary responsibilities are to oversee coordination of care activities for a defined patient panel and to promote population health management by breaking down barriers and providing community, social supports, and health resources to the patient in a primary care setting. The Care Coordinator will work cooperatively with the Practice Manager, Lead Physician, RN Care Manager and other members of the care team to best serve the needs of the identified patient panel. The Care Coordinator will serve as a resource specialist in the primary care setting.

Education:
High School Graduate or higher
Experience:
3 years Medical Office experience and experience navigating the healthcare system
Skills:
* Knowledge of medical and insurance terminology
* Skill in oral and written communication to address inter- and intradepartmental concerns, solve problems and address conflict
* Demonstrated skill in problem solving using available resources in innovative ways
* Skill in providing customer service
* Computer and personal productivity skills to enable effective use of EMR, e-mail, the internet, word processing, spreadsheets, presentation and database packages
* Analytical skills necessary to prepare and interpret reports
* Navigating the health care system and providing resources to patients
* Demonstrate problem solving skills and the ability to research and evaluate innovative ways to use community resources

Patient & Workplace Safety:

• Employee has knowledge and understanding of patient and workforce safety as it relates to job duties.

Patient Population:

• Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.

Principal Duties and Responsibilities:
Actively manage a defined panel of patients. This will include, but not be limited to:* Providing linkages to community resources
* Assisting in scheduling urgent and stat specialty and imaging appointments and obtaining follow-up records
* Following-up to ensure compliance with PCP recommendations, specialist visits, PCP visits, community resources and lab/x-ray
* Following-up with patient after hospitalizations/ER visits, in accordance with policies and procedures
* Executing standing orders for tests and preventative services
* Assess Social Determinants of Health (SDOH) for a defined panel of patients (social, medical, financial, and needs and barriers), assist patients with positive screens with accessing community supports and services, and engage in care planning
* Anticipate the needs of the defined patient panel by preparing for and executing a care team "huddle". This should include seeing that the necessary documentation and pre-visit planning is completed or requested before patient visits
Work with the care team to prevent unnecessary utilization through the following:
* Utilizing CRISP: Notification system for ED and hospital admissions
* Communicating with local hospitals to get the medical discharge summaries
* Collaborating with the RN Care Managers and Providers to come up with plan of care to reduce hospital visits for a defined patient panel
* Working in collaboration with Inpatient Care Management and Coordination teams to ensure warm handoffs are provided for patients coming to the ED, hospital or who have recently been discharged from the hospital
* Engage in patient outreach and care planning through frequent contact and communication the care team, patient and family for defined patient panel; document outreach
* Handle urgent on-call patient needs after hours, as needed
* In conjunction with the patient, physician, family and other members of the care team, the payer and available resources makes referral for transitions in care (such as, nursing home, rehabilitation and sub-acute care) and durable medical equipment for the patient population that he/she manages
Build relationships with local agencies throughout the community, to assist patients with getting the services they need:
* Local Health Department
* Home Health Agencies
* Public Transportation
* Mental Health Providers
* Drug/Alcohol Rehab Facilities
* Homeless Shelters
* Specialists
* Radiology
* Insurance Carriers
* Private and not--for-profit businesses, including:
* Fitness Centers
* Meals on Wheels
* Volunteers
* Work to identify and close gaps in care for a defined patient panel and work collaboratively with Centralized Care Coordinator to ensure seamless patient outreach
* Monitor population management data and reports to ensure patients' health and social needs are being addressed. Develop targets to improve and/or action plans for areas in need of improvement
* Prioritizes care management activities in order of greatest patient need and system need to achieve optimum quality and cost outcomes. Meet productivity standards
* Utilize Quality Improvement plan for reporting and improvement strategies, (PDSA) and Lean Daily Management (LDM)
* Attend staff and committee meetings including office based Advanced Primary Care/PCMH meetings and care management meetings

All roles must demonstrate GBMC Values:

Respect

I will treat everyone with courtesy. I will foster a healing environment.

• Treats others with fairness, kindness, and respect for personal dignity and privacy

• Listens and responds appropriately to others' needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

• Meets and/or exceeds customer expectations
• Actively pursues learning and self-development
• Pays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

• Sets a positive, professional example for others
• Takes ownership of problems and does what is needed to solve them
• Appropriately plans and utilizes required resources for various job duties
• Reports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

• Works cooperatively and collaboratively with others for the success of the team
• Addresses and resolves conflict in a positive way
• Seeks out the ideas of others to reach the best solutions
• Acknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

• Demonstrates honesty, integrity and good judgment
• Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

• Embraces change and improvement in the work environment
• Continuously seeks to improve the quality of products/services
• Displays flexibility in dealing with new situations or obstacles
• Achieves results on time by focusing on priorities and manages time efficiently

Pay Range

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

COVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.