Quality Care Coordinator

1 month ago

Martinsburg, West Virginia, United States Shenandoah Community Health Full time
Job Title: Quality Care Coordinator

Shenandoah Community Health (SCH) is a Federally Qualified Health Center dedicated to providing access to healthcare by reducing barriers to care.

Our comprehensive range of services includes primary care, women's health, behavioral health, oral health, HIV case management, pharmacy, lab, radiology, and various support services.

We offer interpretation services for patients whose primary language is not English.

This is an opportunity to make a meaningful impact on the lives of individuals in our community.

Job Summary:

This position is primarily responsible for providing safe, consistent, and appropriate patient care within their scope of practice.

As an advocate for patients, you will handle a diverse range of situations and responsibilities.

You will work in a multi-disciplinary team and possess strong communication skills.

This role focuses on quality improvement, data entry, and information retrieval to enhance patient outcomes and Shenandoah Community Health's financial viability.

Key Responsibilities:
  • Perform duties with opportunity for independent judgment under general supervision.
  • Conduct telephone and face-to-face outreach to assigned patients to improve their understanding of their health and the measures taken to manage their current health problems.
  • Responsible for researching, analyzing, planning, implementing, and monitoring procedures and processes related to patient outcomes, quality improvement, UDS measures, and HEDIS audits.
  • Use ACO and other payer's APPS/websites to assist in closing care gaps, performing TCM and ED/Hospital Discharge follow-up, scheduling AWVs, and referring patients to ACO programs.
  • Enter information into Electronic Medical Record (EHR).
  • Schedule appointments, keep medical records current, and work with insurance companies.
  • Attend in-person or virtual meetings with ACO, MCO's, and private insurers.
  • Participate in weekly Care Coordination Meetings.
  • Provide education and problem-solving with patients to identify and address specific goals to support health and behavior/lifestyle change using assessment tools under the supervision/directions of the provider.
  • Offer appropriate interventions to optimize health and well-being.
  • Perform effective pre-Adult Wellness Visit (AWV) assessments, including health risk assessments, patient/family medical history, current medications, allergies, depression, and functional activity screenings.
  • Collaborate with other members of the Primary Care Home Team to implement a plan of care for patients.
  • Work as a liaison between the physician, patient, and family to improve quality and deficiency of care.
  • Demonstrate flexibility, open-mindedness, and versatility in adjusting to changing environments and requirements.
  • Demonstrate courteous and cooperative behavior with patient families, coworkers, subordinates, supervisors, and other department staff.
  • Maintain patient confidentiality and privacy according to SCH policies and procedures.
  • Act as a role model for ancillary personnel.
  • Practice within the limits of the Nurse Practice Act and understand legal consequences of nursing action.
Qualifications:
  • A graduate from a Medical Assistant Program with an active unencumbered MA Certification in WV/VA (PREFERRED).
  • Demonstrated ability to function effectively within a multi-disciplinary team.
  • Excellent skills in patient communication and education.
  • Strong time management skills and attention to detail.
  • Strong computer skills, with experience working with an Electronic Health Record.
  • Strong understanding of Quality Measures, UDS, and Meaningful Use.
  • Annual basic CPR certification is also required.

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