Care Coordinator I or II

1 week 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 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 by assessing gaps in care for patients with chronic conditions and/or mental health needs.

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 management of their chronic illness, 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 who have been seen in an emergency room and/or have been 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.
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. For example, Full-time employees working 30 hours or more, receive an excellent benefit package of:

  • 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
  • 401(k)/Retirement options

We also offer an exciting opportunity to work in a culturally diverse environment.

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