Clinical Care Coordinator
2 weeks ago
About the Organization
Community Health Programs is a comprehensive network of healthcare facilities and dedicated professionals committed to delivering exceptional primary and preventive care for individuals of all ages.
What sets CHP apart is our extensive range of support services that go beyond medical and dental care, aimed at empowering families and enhancing children's health.
The region is recognized as a federally designated rural community and a Medically Underserved Population Area.As a nonprofit healthcare provider and community ally, Community Health Programs takes pride in its leadership role by offering high-quality healthcare, dental services, wellness education, and family support initiatives.
Our outreach efforts include complimentary health screenings, assistance with insurance enrollment, and resources to educate individuals on improving their health and that of their families.
Position Overview
Salary:
$70,000 - $90,000 / Annually
Summary:
The Clinical Care Coordinator (CCC) is responsible for conducting thorough patient evaluations to manage healthcare requirements throughout the care spectrum.
This position focuses on enhancing individual health and self-management capabilities through collaboration with a multidisciplinary team, which includes behavioral health specialists and community health workers.
Key duties involve conducting in-person visits for members needing direct interactions and assessments.The objective is to coordinate and facilitate services that align with member needs, considering benefit structures and available community resources.
The CCC, in partnership with the interdisciplinary team, will formulate patient care plans in collaboration with the patient, ensuring cost-effective and high-quality outcomes centered on the outpatient setting.
Working closely with healthcare providers, office personnel, care management teams, and community partners, the CCC will oversee member care.
This role will uphold CHP's mission, vision, and values while adhering to compliance protocols and organizational policies.
Key Responsibilities
The Clinical Care Coordinator will:
- Assess and manage a panel of members.
- Conduct face-to-face visits for onboarding new members and reassessing existing ones, utilizing various interviewing techniques to:
- Evaluate a member's clinical and functional status to identify ongoing special conditions and
- Develop and implement a personalized, coordinated care plan in collaboration with the member, clinical team, primary care providers, specialists, and other community partners to ensure a cost-effective quality outcome.
- Execute Transitional Care Management (TCM) in accordance with program and product line processes.
- Stay informed about program benefits, Plan Handbook details, and departmental policies. Follow established procedures to educate members and providers, advocating for member rights and providing necessary information.
- Advocate for members to ensure they receive appropriate benefits.
If member needs are identified and they are not eligible for coverage, collaborate with community agencies to connect members with additional services, such as transportation, food programs, and senior center resources.
- Adhere to department and regulatory standards to authorize and coordinate healthcare services, ensuring timely compliance with documented care plan goals and objectives.
- Assess members' understanding of their current disease management and medication regimens, providing education to enhance member and caregiver knowledge, and assisting members in learning how to self-manage their health, social, or behavioral health needs.
- Work with the interdisciplinary team to identify and address rising and high-risk members.
- Educate members on preventive screenings and other healthcare procedures, such as vaccinations and screenings, according to established protocols.
- Ensure members and their representatives participate in the development and approval of their care plans in conjunction with the interdisciplinary primary care team.
- Support Quality and Ad-Hoc campaigns.
- Provide culturally competent care coordination, including working with interpreters, providing communication-approved documents in appropriate languages, and demonstrating culturally sensitive behavior when interacting with members, families, caregivers, and/or authorized representatives.
- Collaborate with members and their representatives to develop member-centered care plans by identifying care needs while completing program assessments and working with members to approve their care plans.
- Monitor the progress of member goals and care plan objectives, providing feedback and collaborating with care team members to coordinate a continuum of care aligned with the member's healthcare goals and needs.
- Build and maintain relationships with members, families, caregivers, vendors, and providers to ensure optimal collaboration and coordination of healthcare needs, promoting timely, cost-effective, and high-quality care.
- May coordinate and/or attend in-person member/provider visits, care plan meetings with providers and office staff, and may lead care plan reviews with providers and care teams as applicable.
- Perform other responsibilities as assigned by the Manager or designee.
- Support department colleagues by covering and assuming changes in assignments as directed by the Manager or designee.
- Identify high-risk patients by reviewing monthly risk stratification data.
Competencies:
To perform this role successfully, an individual should demonstrate the following competencies:
- Excellent communication and interpersonal skills with members and providers via telephone and in person.
- Exceptional customer service skills and a willingness to assist in ensuring timely resolutions.
- Strong organizational skills and the ability to manage multiple tasks effectively.
- Appreciation and adherence to policy and process requirements.
- Independent learning skills and success with various learning methodologies.
- Willingness to learn about insurance regulatory and accreditation requirements.
- Proficiency in software systems, including but not limited to Microsoft Office Products - Excel, Outlook, and Word.
- Familiarity with Excel spreadsheets for managing work and exposure, including pivot tables.
- Accurate and timely data entry.
- Effective case management and care coordination skills, with the ability to assess a member's daily living activities and develop and implement a care plan that meets the member's needs.
- Knowledge of community resources, levels of care, and criteria for levels of care, with the ability to develop and implement a care plan following regulatory guidelines and level of care criteria.
Essential Skills and Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Experience:
- 2+ years of clinical experience as a Registered Nurse working with diverse age groups.
- Experience working with individuals on MassHealth coverage who may be facing social, economic, and/or complex medical and behavioral health conditions is preferred.
- Ability to communicate and collaborate with primary care providers, community, and ACO partners to manage member care is required.
- Experience with telephonic interviewing skills and working with a diverse population, including non-English speakers, is required.
- Home Health Care experience is preferred.
- Experience working in a community social service agency, skilled home health care agency, or state agency such as the Department of Mental Health (DMH), Department of Developmental Services (DDS), Department of Children and Families (DCF), or the Department of Youth Services (DYS), or other agencies serving those in need is preferred.
- Effective case management and care coordination skills, with the ability to assess a member's daily living activities and develop and implement a care plan that meets the member's needs in partnership with a care team is preferred.
- Experience with self-scheduling of caseload is preferred.
Education and Training:
- Registered Nurse required.
- Bachelor's (or advanced) degree in nursing or a healthcare-related field is preferred.
- Graduate of a N.L.N. accredited nursing program.
- CPR certification is required every two years.
License, Certification & Registration:
- RN - License as a professional nurse within the state.
- Active and valid driver's license.
Full-Time/Part-Time
Full-Time
Position
Pediatric Population Health Nurse
Exempt/Non-Exempt
Exempt
EOE Statement
We are an equal employment opportunity employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.
This position is currently accepting applications.
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