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Chronic Care Management Specialist
2 months ago
Sea Mar Community Health Centers is a community-focused organization dedicated to delivering comprehensive health, human, housing, educational, and cultural services to diverse populations, particularly serving the Latino community in Washington State. We are currently seeking qualified candidates for the following role:
Care Coordinator II
Compensation: $22.63 per hour
Role Summary:
This full-time position is available at our Everson Medical Clinic. The selected candidate will be tasked with coordinating care for patients with chronic health conditions and behavioral health requirements at the point of service. As an integral member of the Clinical Care Team, the Care Coordinator will engage in daily team meetings, assess patient needs following established protocols, and deliver on-site care services. The role aims to enhance the quality and patient-centered approach to care at Sea Mar Community Health Centers.
Key Responsibilities:
- Engage in daily team meetings to proactively address the clinical, social, and behavioral health needs of patients.
- Collaborate with the care team to identify and address gaps in patient care through process improvement initiatives.
- Provide brief interventions at the point of care to assist patients in managing chronic illnesses and addressing social needs, while connecting them to behavioral health resources.
- Advocate for patient services within the community, liaising with social service and medical providers.
- Facilitate care transitions for patients discharged from emergency rooms or hospitals.
- Monitor patient adherence to care plans, documenting outcomes and recommendations for primary care providers.
- Serve as a key resource within the clinic care team for chronic disease management and quality improvement activities.
- Organize and lead monthly Health Home meetings, collaborating with the Clinic Operations Team to create agendas and facilitate discussions.
- Work with the clinical care team to enhance Patient-Centered Medical Home processes and provide documentation of performance metrics.
- Review medical records for quality and utilization indicators in line with the Quality Improvement Plan.
- Generate reports for care teams to identify improvement areas and track the sustainability of quality measures.
Qualifications:
To be successful in this role, candidates must demonstrate the ability to perform essential duties effectively. The following qualifications are required:
- Ability to work independently, prioritize tasks, and meet deadlines.
- Strong critical thinking skills and commitment to confidentiality.
- Excellent organizational skills with the capacity to manage multiple tasks simultaneously.
- Familiarity with medical terminology and behavioral health topics.
- Proficient decision-making and prioritization abilities.
- Ability to interact respectfully and professionally with patients, families, and community members.
- Experience working effectively in a multicultural environment.
- Empathetic, responsible, and dependable demeanor.
- Strong patient engagement, interpersonal, and communication skills, with the ability to build therapeutic relationships.
Knowledge, Skills, and Abilities:
- Understanding of the Patient-Centered Medical Home Model and motivational interviewing techniques is advantageous.
- Knowledge of evidence-based care standards for chronic and behavioral health conditions.
- Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).
- Ability to document relevant patient information in Electronic Health Records.
- Familiarity with community resources.
- Capacity to thrive in a fast-paced community health care environment.
- Analytical thinking and problem-solving skills in both team and independent settings.
- Ability to manage challenging interactions effectively.
- Effective communication skills with diverse communities.
- Time management skills with the ability to prioritize tasks efficiently.
- Ability to analyze patient care data and assess client learning needs.
- Commitment to maintaining the privacy and security of sensitive information in all formats.
- Exceptional communication and customer service skills.
- Critical thinking and process improvement skills.
- Bilingual in Spanish is highly preferred; other language skills may be considered based on community needs.
Education and Experience:
- LPN with experience in ambulatory care or a BA/BS/BSW in a health-related field with at least one year of experience in community health, or four years of equivalent experience. Note: The LPN does not require an active license as this is a non-licensed position.
- Basic Life Support (BLS) CPR certification is required within 90 days of hire and must be maintained throughout employment.
- NCQA Certification is a plus.
- A valid Washington State Driver's License and proof of liability insurance are required.
What We Offer:
At Sea Mar, we provide talented individuals with the opportunity to work in a dynamic and expanding community health organization. Joining Sea Mar Community Health Centers means more than just a job; it is a rewarding career with opportunities for advancement. Our benefits package is competitive and includes:
- Medical, Dental, and Vision coverage
- Prescription drug coverage
- Life Insurance
- Long-Term Disability
- Employee Assistance Program (EAP)
- Paid time off starting at 24 days per year plus 10 paid holidays
We also offer 401(k) and retirement options, along with a vibrant and culturally diverse work environment.
Equal Opportunity Employer