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Chronic Care Coordinator

2 months ago

Everson, Washington, United States Sea Mar Community Health Centers Full time
Position Overview

Sea Mar Community Health Centers is a community-focused organization dedicated to delivering high-quality, comprehensive health and social services to diverse populations, particularly serving the Latino community in Washington State. We are currently seeking a dedicated individual for the role of Care Coordinator II.

Role Summary:

This full-time position is based at our Everson Medical Clinic. The Care Coordinator will play a crucial role in managing care for patients with chronic illnesses and behavioral health challenges. 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 provide essential services at the point of care. The primary goal is to enhance the quality of care and ensure a patient-centered approach.

Key Responsibilities:

  • Engage in daily team huddles to proactively address the clinical, social, and behavioral health needs of patients.
  • Collaborate with the care team to identify and rectify gaps in patient care using improvement strategies.
  • Deliver brief interventions at the point of care to assist patients in managing chronic conditions and addressing social needs.
  • Advocate for patient services with community organizations, social services, and healthcare providers.
  • Facilitate care transitions for patients discharged from emergency rooms or hospitals.
  • Monitor patient adherence to care plans and communicate outcomes to primary care providers.
  • Serve as a key resource within the clinic for chronic disease management and quality improvement initiatives.
  • Organize and lead monthly Health Home meetings in collaboration with the Clinic Operations Team.
  • Work with the clinical team to enhance Patient-Centered Medical Home processes and document performance metrics.
  • Review medical records for quality assurance and utilization metrics as per the Quality Improvement Plan.
  • Generate reports to identify improvement areas and sustain quality measures.

Qualifications:

  • Ability to work independently, prioritize tasks, and meet deadlines.
  • Strong critical thinking skills and commitment to confidentiality.
  • Excellent organizational capabilities and ability to manage multiple tasks.
  • Familiarity with medical terminology and behavioral health topics.
  • Strong decision-making and prioritization skills.
  • Ability to interact respectfully and professionally with diverse communities, patients, and staff.
  • Experience working effectively in a multicultural environment.
  • Demonstrated empathy, maturity, and reliability.
  • Exceptional patient engagement and communication skills.

Knowledge and Skills:

  • Understanding of the Patient-Centered Medical Home Model and motivational interviewing techniques is advantageous.
  • Knowledge of evidence-based practices for chronic conditions and behavioral health.
  • Proficiency in Microsoft Office Suite and Electronic Health Records.
  • Ability to analyze patient care data and identify learning needs.
  • Commitment to maintaining the privacy and security of sensitive information.
  • Bilingual in Spanish is preferred; other language skills may be beneficial based on community needs.

Education and Experience:

  • LPN with experience in outpatient care or a BA/BS/BSW in a health-related field with at least one year of community health experience, or equivalent experience.
  • Must obtain Basic Life Support (BLS) CPR certification within 90 days of hire and maintain it throughout employment.
  • Valid Washington State Driver's License and proof of liability insurance are required.

What We Offer:

At Sea Mar, we provide a supportive environment for talented individuals to grow within a dynamic community health organization. Our comprehensive benefits package includes:

  • Medical, Dental, and Vision Insurance
  • Prescription Coverage
  • Life Insurance and Long-Term Disability
  • Employee Assistance Program (EAP)
  • Generous Paid Time Off and Holidays

We also offer 401(k) and retirement options, along with the opportunity to work in a culturally diverse setting.

Equal Opportunity Employer