The duties of this position involve care coordination for patients within the Primary Care Physician practice. The care coordinator works to implement and provide ongoing support of the care management program in collaboration with the primary care team. This will include supporting the primary clinical teams in monitoring health promotion, disease management, and care coordination. The Care Coordinator will work with the Primary Care Physician, Care Manager, and Practice Manager to best serve the needs of the patient and the primary care teams.
Responsibilities
Care Management
Work with all clinical teams as a resource on care management.
Pre-visit planning workflow to ensure care completion prior to visit whenever possible.
Use of efficient, accurate point of care reminders for evidence-based care.
After visit summary review with patients whenever appropriate.
Discuss with physicians and follow up appropriately to ensure smooth transition of care for patients treated in a facility (inpatient or emergency department), by specialty physicians, or by another health care provider.
Involve the patients in activities to improve their health (patient engagement).
Educate the patient about self-management tasks they can undertake to gain greater control of their health status.
Facilitate referrals to other providers.
Communicate regularly with patients to promote proactive health management.
Assist with scheduling follow-up appointments, regular visits, and referral appointments.
Clinical Quality and Performance
Work closely with providers as well as clinical staff to assure clinical quality is an ongoing priority in all phases of patient care.
Facilitate advanced management of care to an identified population.
Coordinate patient care services for selected patients across the continuum of care through collaboration with the patient, family, and health care providers in achieving optimal patient outcomes.
Participate in clinical quality activities and facilitate implementation of clinical best practices.
Coordinate with physician leadership and RN Care Managers to develop strategies for the high-risk patient population to coordinate patient care from office to hospital to home.
Customer Service
Provide the highest level of customer service to achieve the goal of "putting patients first".
Promote excellence in healthcare delivery to the patient and/or patient family. Identify and facilitate implementation of clinical best practices.
Engage co-workers and patients in a positive, respectful manner.
Show respect and sensitivity for differences among co-workers and patients.
Act as a point of contact to problem-solve for the patient and clinical staff.
Conduct telephone callbacks to patients requiring follow-up care.
Support the clinical staff with health teaching and health counseling to patients and/or their families.
Facilitate a seamless transition through the healthcare system.
Information Technology
Ensure complete and accurate documentation in the medical record.
Design effective workflows using population management software, the electronic medical record, and registries.
Collect and monitor data related to outcomes.
All other duties as assigned.
Qualifications
KNOWLEDGE AND SKILLS:
Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.
EDUCATION: High school graduate. Certification in a healthcare field such as a medical assistant or patient care assistant or college degree preferred.
YEARS OF EXPERIENCE: Minimum of 2 years experience as an MA, PCA, or other related healthcare role.
REQUIRED SKILLS AND KNOWLEDGE:
Self-motivated
Superior communication skills: Able to effectively communicate with others, both written and verbally.
Possess critical thinking and problem-solving skills.
Ability to prioritize work, and manage multiple demands.
Knowledge of basic computer functions.
Ability to work both with and for the team.
Ability to show respect and sensitivity to cultural differences in both employees and patients.
Knowledge and support of organization's goals and values.
Reliable and punctual.