CARE COORDINATOR - Military Veterans

SUMMARY OF POSITION:

The Care Coordinator (CC) reports directly to the Lead Care Coordinator. This position is responsible for care coordination and care management for all patients with chronic conditions, in collaboration with the other members of the care team. The CC performs health maintenance checks, coordinates appointments for cancer screenings, and follows up with all patients without clinical visits for six months or more, patients diagnosed with depression, patients diagnosed with asthma, obesity, and other conditions. The CC is responsible for accurate and timely documentation of all tasks and patient contacts in the electronic medical record, assisting in planning and implementation of programs, preparing reports and evaluations, and performs other duties as required.

TYPICAL PHYSICAL DEMANDS/WORKING CONDITIONS:

Requires prolonged sitting, some bending, stooping, and stretching.  Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, and other office equipment. Requires normal range of hearing and eyesight to record, prepare, and communicate appropriate forms and records. Requires working under deadline pressure.

ORGANIZATIONAL COMMITMENTS: 

As a mission-driven organization, we are committed to providing patient-centered care.  All employees are required to be aware of the organization’s practice of the NCQA’s Patient-Centered Medical Home model and the Institute for Healthcare Improvement’s (IHI) Model for Improvement, as well as evidence-based guidelines from the National Institute on Minority Health and Health Disparities (NIMHD).

ESSENTIAL FUNCTIONS:

·            Plans and integrates care for people with chronic diseases

·            Provides ongoing support and expertise through comprehensive assessment, planning and support of individual patient needs

·            Collaborates with High-Risk Nurse Care Managers (HRNs) to complete care plans and assists patients with self-management goals in accordance with Whittier’s Boston Health Equity Project (BHEP) and Quality Assurance Plan.

·            Participates in development and implementation of patient care policies

·            Facilitates team communication and huddles

·            Assists in planning and implementing programs and projects to improve quality and efficiency of clinical, educational, and administrative services and operations, and assists in the preparation of reports and evaluations as needed. In addition, the CC will act as a community liaison for public health efforts towards healthier communities.

·         Schedules patients, confirms all appointments, medical records – pulls all charts for established patients

·         Documents in patient records, patient contact attempts, and patient telephone and written communications

·         Logs appointment dates, times, and locations; checks off if the letter was sent, phone calls were made and films requested

·         Reviews charts for missing documentation

·         Coordinates care with other team members

·         Assists with referrals and links to community resources

·         Assists with counseling regarding self-management goals

·         Provides patient education on health issues related to chronic diseases

·         Assists with facilitating and organizing group process

·         Works internally with all Chronic Care Provider Champions

·         Provides support to patients requiring home visits

·         Conducts community outreach when needed

·         Maintains steps to integrate Improvement efforts into the day –to- day activities

·         Provides additional information as required to funding sources

·         Ensures and maintains all necessary documentation, consent forms

·         Performs other duties as requested

Required Experience/Abilities/Competencies:

·         Working Knowledge of medical terminology

·         Experience working in a community based agency with a diverse population

·         Effective organizational and interpersonal skills

·         Experience in community outreach

·         Computer literate with knowledge of Microsoft Office, Clinical Systems and Decision Support Systems

·         Excellent interpersonal, organizational, analytical, communication and customer service skills

·         Ability to work with multidisciplinary teams

·         Ability to be flexible, demonstrate self-initiation and the ability to work independently

Licensure/Education/Training:

·         Bachelor’s degree or higher in Social Work, Nursing, Public Health, or other relevant field from accredited college or university, with relevant work experience.

·         Licensed Practical Nurses (LPNs) may be considered.