Patient Care Coordinator
2 weeks ago
POSITION SUMMARY:
The Patient Care Coordinator is responsible for providing advocacy, outreach, education, and clinical services to patients. Essential skills for this role include effective communication, cultural sensitivity, and relevant professional training. The responsibilities are designed to cater to the specific needs of diverse communities. Key duties include:
- Enhancing connections between at-risk populations and the healthcare system;
- Managing care transitions for vulnerable groups;
- Delivering culturally relevant health education on chronic disease prevention, nutrition, and physical activity;
- Advocating for marginalized individuals to access necessary services;
- Offering informal counseling; and
- Building community capacity to tackle health challenges.
The Patient Care Coordinator must possess a strong understanding of community resources and counseling practices for high-risk populations. Experience in crisis intervention and the ability to work independently with a focused approach are essential. The role requires a task-oriented, nonjudgmental attitude while respecting boundaries. The coordinator must be adept at working in various environments with culturally diverse families, demonstrating cultural competence. Responsibilities include maintaining a caseload and meeting with patients to facilitate their journey towards optimal health or improved functionality. This involves assessing patients' conditions, benefits, and available resources, as well as developing tailored treatment plans with measurable goals and monitoring patient care.
KEY RESPONSIBILITIES:
- Provide comprehensive care management services to patients with chronic illnesses and their support systems, ensuring access to necessary services and coordination of care.
- Gather necessary consents and complete required assessments and care plans in accordance with organizational policies.
- Effectively communicate the objectives of the program to potential patients and community stakeholders.
- Engage in quality improvement initiatives in collaboration with social and community health workers.
- Prepare and submit periodic reports for program evaluation.
- Focus on the homeless population by identifying new patient sources and conducting outreach.
- Regularly meet with supervisors and participate in staff meetings to discuss operational challenges.
- Maintain accurate records of daily activities and update caseloads regularly.
- Ensure patients attend scheduled medical and social service appointments through relationship-building with patients and providers.
- Maintain regular contact with clients based on risk stratification and care plans.
- Address client grievances according to agency guidelines.
- Conduct outreach to engage clients and strengthen connections with service providers.
- Support health maintenance and prevent complications through education and coaching.
- Enhance linkages related to patient care, including social determinants, and monitor their effectiveness.
- Communicate program strengths and areas for improvement with supervisors.
- Facilitate community follow-up to engage clients in care and promote self-sufficiency.
- Identify and pursue professional development opportunities.
QUALIFICATIONS:
- High School Diploma required.
- Bachelor's degree in Social Work or a related field preferred.
- Bilingual (English and Spanish) preferred.
- Six years of case management experience with a High School Diploma/GED or four years with an Associate's degree.
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