Summary: This position provides coordinated care to participants and assists the Care Teams (provider, medical assistant, nurse, behavioral health provider, others) by coordinating care to participants on the provider’s daily schedule and by proactively managing and coordinating care for participants not on the schedule, so as to offer complete preventive care for all participants who are part of the provider’s assigned panel. The position will be involved with the oversight and coordination relating to integrated care, development of individualized care planning, care coordination, case review with Providers, and interacting with Case Managers.
Essential Duties and Responsibilities:
- Orients and educates participants and their families by meeting them, explaining the role of the Care Coordinator, providing Answers and makes appointments for all Health Center Participants, including medical, oral health, case managers, and others.
- Manages assigned participant case load through community outreach, conducting care coordination assessments and creation of related care plans, including social and cultural factors that influence health.
- Participates in periodic evaluative reviews and/or in-house and external staff training to ensure that he/she understands professional standards and continues to adhere to such standards. Initiates requests for assistance or guidance from Supervisor to address new issues or complex concepts affecting adherence to professional standards.
- Assist in routine audits of electronic medical records to ensure completeness of treatment plans
- Participate in daily huddles to identify and assist with participants requiring additional services.
- Assists in letter and telephone campaigns to participants “lost to care”.
- Assists in educating and coaching participants in good healthcare habits.
- Monitors daily alerts for participants entering an emergency room or inpatient hospital through Medical Home Network processes and other coordinated care interfaces, following up with participant and making appointments.
- Documents treatment plans and other vital information in electronic medical record after visits with participants.
- Actively participates in care planning that specifies care coordination by referring to direct care resources to meet physical and psychosocial needs; by prioritizing problems and establishing mutually-agreed upon goals specific to the stage of participant activation; by using program planning and group concepts to meet the health needs of the special populations.
- Participates as assigned in participant education including development of materials, conducting presentations or supporting other team members in such efforts.
- Utilizes experience and training to advocate, mentor, and support other team members (including social workers and community health workers) for accomplishment of overall care coordination goals
- Evaluates utilization data at the individual and population health level and uses this to inform the care coordination process.
- Collaborates with other multidisciplinary professionals and community agencies to provide a continuum of coordinated care addressing health and related social determinants.
- Participates in quality improvement activities as assigned.
- Documents comprehensive, accurate, and continual data on client records and program reports.
- Collaborates with the health care professionals on behalf of special populations to provide participant health education.
- Performs other duties as assigned.
- Saturday hours may be necessary on occasion.
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.
- Education: Bachelor’s degree required.
- Experience: At least two years related experience working with vulnerable populations and/or Medicaid recipients required. Previous work in community-based, public health or managed care is preferred.
- Other Qualifications: Ability to calmly and politely interact with callers to accurately define their question or concern.
- Computer Skills: Demonstrated computer proficiency, including knowledge of word processing, spreadsheet and database software.
- Language Skills: Ability to write reports, correspondence, and instructions. Ability to effectively present information and respond to questions from staff, managers, participants, vendors, and the general public. Bilingual Spanish preferred but not required.
- Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Competencies: To perform the job successfully, an individual should demonstrate the following competencies.
- Communication: Excellent verbal and written communication skills.
- Mathematical: Proficient math and computer skills.
- Organizational Support : Strong organizational skills.
- Reasoning : Ability to synthesize information quickly.
- Problem solving : Ability to identify and resolve problems in a timely manner.
- Gathers and analyses information skillfully and develops alternative solutions
- Problem Solving : Works well in group problem solving situations. Uses reason when dealing with emotional topics.
- Motivation: Sets and achieves challenging goals. Demonstrates persistence and overcomes obstacles.
- Ethics : Treats people with respect. Keeps commitments. Inspires the respect of others.
- Planning/Organizing : Prioritizes and plans work activities. Uses time effectively. Plans for more resources
- Professionalism: Approaches others in a tactful manner. Reacts well under pressure. Treats others with respect.
- Quality: Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality.
- Safety and Security: Observes safety/ security procedures. Determines appropriate action beyond guidelines.
- Dependability: Follows instructions, responds to management direction. Takes responsibility for actions.
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel and talk or hear.
- The employee is frequently required to reach with hands and arms.
- The employee is occasionally required to stand; walk; sit; climb or balance; and stoop, kneel, crouch, or crawl.
- The employee must occasionally lift and/or move up to 40 pounds.