Lead Care Coordinator
2 days ago
We are seeking a highly skilled and experienced Lead Care Coordinator to join our team at Saban Community Clinic. As a key member of our clinical team, you will be responsible for leading and providing training, coaching, and ongoing support to our Care Coordination team members.
Key Responsibilities- Lead the performance of Health Risk Assessments and initiate plans for eliminating social determinants of health identified in clinically based assessments.
- Lead staff who provide medical coordination assistance for patients referred to/from providers, Care Managers, and from any other provider.
- Schedule medical and specialty appointments, provide reminder phone calls for appointments, and follow-up calls post-appointment as needed.
- Participate in Patient-Centered team meetings aimed at improving patient outcomes or operational processes.
- Lead clinical cross-care team meetings with Providers and Care Managers to identify clinically based priorities, tasks, and interventions.
- Maintain timely and appropriate documentation on patient interactions in the EHR, EPIC.
- Provide important updates to the primary care provider and Care Managers regarding patient progress towards clinically based self-care management as needed.
- Provide culturally appropriate support and information for patients and their families through follow-up phone calls and make reminder calls as needed.
- Assist patients with adherence to existing clinical self-management goals or development of new goals as needed.
- Work with each patient closely to ensure they are meeting the goals set for in their care management plans as needed.
- Lead coordination of continuity of patient care with internal and external healthcare organizations and facilities, coordinates information and care requirements with other care providers.
- Ensure staff provide timely follow-up with provider post-hospitalization/emergency room visit; retrieve discharge summaries and copies of medical records.
- Ensure staff provide home and facility visits, if necessary, to ensure patients are following their plan of care.
- Lead maintenance and dissemination of the chronic care model to all appropriate Clinic staff.
- Pursue new and more efficient ways to provide excellent patient and staff experiences.
- Serve as liaison between frontline clinic staff and clinicians or other appropriate clinic staff.
- Perform population management activities as assigned.
- Bachelor's or Associate degree in health or social services or at least 4 years of experience in a clinical setting.
- Proficient computer skills, including Microsoft Office (specifically Word and Excel).
- Knowledge of EPIC required and ability to enter data.
- Self-disciplined, energetic, passionate, and innovative. Demonstrates ability and desire to relate to and work with people of all ages, social, and ethnic backgrounds and to convey a sense of confidence and trust to all patients.
- Highly organized and well-developed oral and written communication skills.
- Able to maintain confidentiality with all aspects of information in accordance with practice, State, and Federal regulations.
- Ability to assist in the facilitation and coordination of patient care plans.
- Background in health education and experience is preferred.
- Covid-19 vaccination required as a condition of employment as required by State law. Medical and religious exemptions may apply.
The Saban Community Clinic was founded in 1967 on the principle that healthcare is a right, not a privilege. It is our mission to provide affordable quality Whole Person Care to everyone regardless of income or immigration status in a caring environment. This includes medical, behavioral health, and dental care.
Saban Community Clinic values the diversity of the people it hires and serves. Diversity at Saban means fostering a workplace in which individual differences are recognized, appreciated, respected, and responded to in ways that fully develop and utilize each person's talents and strengths. We are an Equal Opportunity Employer. We do not discriminate on the basis of race, religion, color, sex, age, national origin, gender identity, sexual orientation, or disability.
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