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Care Coordinator I or II Position

2 months ago

Grand Rapids, Michigan, United States SeaMar Community Health Centers Full time
Job Title: Care Coordinator I or II

Sea Mar Community Health Centers is seeking a dedicated and compassionate Care Coordinator I or II to join our team. As a Care Coordinator, you will play a vital role in enhancing quality and patient-centered care for our patients.

Job Summary:

The Care Coordinator will be part of a clinical care team, responsible for assessing gaps in care for patients with chronic conditions and/or mental health needs. You will create a plan with the clinical care team during daily huddles, assist patients with medication management, access to insurance, and help identify preventive health needs. Additionally, you will assist patients with ongoing self-management goal setting using Motivational Interviewing skills.

Key Responsibilities:
  • Participate in morning huddles to anticipate patient clinical, social, and behavioral health needs.
  • Work with the care team to identify gaps in care and resolve them using process improvement strategies.
  • Provide brief interventions at point of care to assist patients with chronic illness management, address social needs, and link patients to behavioral health.
  • Advocate for patient services with community, social service, and medical providers.
  • Participate and coordinate care transitions for patients seen in an emergency room and/or discharged from a hospital/long-term care facility.
  • Track patient adherence with plan of care in electronic or paper charts and communicate outcomes and recommendations to the primary care provider.
  • Function as a point person within the clinic care team regarding chronic disease management and improvement activities to improve clinical quality measures.
  • Organize monthly Health Home meetings by working with the Clinic Operations Team/Clinic Manager, create the agenda, and help facilitate the meeting.
  • Collaborate with clinical care team to improve Patient-Centered Medical Home processes and provide documentation demonstrating performance.
  • Review the medical record for quality and utilization indicators according to the Quality Improvement Plan.
  • Generate reports for care teams to identify areas of improvement and monitor sustainability of each quality measure.
Requirements:
  • Must be able to work independently, prioritize workload, and meet deadlines.
  • Must have critical thinking skills and maintain confidentiality.
  • Excellent organizational skills and ability to handle a variety of tasks simultaneously.
  • Knowledge of medical terminology and/or behavioral health topics.
  • Strong decision-making and prioritization skills.
  • Ability to work respectfully and professionally with the community, patients, families, and staff.
  • Able to work effectively in a multi-cultural environment with a diverse population.
  • Sympathetic, mature, responsible, and reliable.
  • Strong patient engagement, interpersonal, and communication skills and ability to establish a therapeutic relationship with the patient.
Preferred Qualifications:
  • Knowledge of the Patient-Centered Medical Home Model and Motivational Interviewing skills.
  • Knowledge of evidence-based standards of care for chronic conditions and behavioral health issues.
  • Knowledge of and proficient in Microsoft Word, Excel, PowerPoint, and Outlook.
  • Ability to utilize and document relevant patient information in the Electronic Health Record.
  • Knowledge of community resources.
  • Ability to work in a fast-paced community health care setting.
  • Ability to think analytically and problem-solve in a multidisciplinary team and independently.
  • Ability to deal effectively with difficult people and situations.
  • Ability to communicate effectively with diverse communities.
  • Ability to manage time effectively and prioritize tasks.
  • Ability to analyze patient care data.
  • Ability to identify client learning needs and assess client's knowledge, skill level, and readiness for learning.
  • Ability to maintain the privacy and security of sensitive and confidential information in all formats, including verbal, written, and electronic, and adhere to policies and procedures related to local, state, and federal privacy requirements.
  • Excellent communication and customer service skills.
  • Critical thinking skills.
  • Ability to understand and implement process improvement activities.
  • Bilingual in Spanish is strongly preferred. Other language skills may be considered depending on site needs due to the population being served.
What We Offer:

Sea Mar Community Health Centers offers talented and motivated people the opportunity to work in a dynamic and growing community health organization. Working at Sea Mar Community Health Centers is more than just a job, it's a fulfilling career with opportunity for advancement. The fringe benefits surpass most companies, including medical, dental, vision, prescription coverage, life insurance, long-term disability, EAP (Employee Assistance Program), paid-time-off starting at 24 days per year + 10 paid Holidays, and 401(k)/Retirement options.