Position SummaryThe Care Coordinator is a Licensed Social Worker or Counselor who provides care coordination, social support services and outreach services to assist patients in navigating health care transitions, and support patient empowerment through health education, advocacy and coaching. The Care Coordinator ensures the continuity and quality of care for patients and provides care coordination with a Triple Aim approach in mind: Improve the patient experience, improve population health and lower the cost of health care.Core Job Responsibilities•Serve as team lead for intake process, development and maintenance of care plan and promoting health programs and services.•Utilize information systems and decision support, manages a patient panel to proactively contact, educate, and track patients by disease, risk, and self-management status, as well as family and community need.•Lead Patient-Centered Care Planning including assessment, plan, implementation/intervention and evaluation, as well as a method for monitoring and intervening.•Conduct home/community visits (face-to-face) according to policy and workflows.•Provide resources to support patient/families in self-management to meet health care treatment goals, assess readiness to learn and validate learning outcomes.•Purposefully engage patients and/or families to voice care-related questions and concerns and recognizes individual expertise of the patient by coaching and counseling.•Facilitate pre-planning, patient education and empowerment, and assessment of patient barriers to support the most effective and efficient interactions between patients and providers.•Work collaboratively with interdisciplinary teams and health care team members both internal and external to the organization to improve patient care through effective utilization and monitoring of health care resources.•Assist patient and providers from across the care continuum in the transition from outpatient- to inpatient setting, and ensure post-emergency department, hospitalization, and/or specialist follow up.•Appropriately and in a timely manner, document interactions, findings, and continuum of care-related activities in the electronic medical record to assure optimal patient care reporting on quality improvement efforts.•Participate in evaluating outcomes at the individual level with each patient/client and at the same time participate in agency-wide evaluative efforts to ensure and improve the overall quality of service being delivered.•Work collaboratively with the quality department to improve patient outcomes through the review of patient care gaps, educating patients on the importance of prevention care and ongoing needed assessments, remain aware of quality initiatives and ACCESS quality priorities.•Perform other duties as assigned.Requirements/Preferences•Bachelor’s degree required, Master’s degree preferred•Current, unrestricted Illinois license: LCPC, LPC, LCSW or LSW required•Minimum two (2) years’ experience in a clinical setting required.•Care Coordination experience preferred.•Bilingual Spanish a plus.•Previous experience using an electronic medical record preferred.•Intermediate proficiency in Microsoft Office products (Word, Excel, PowerPoint) required.Competencies/Behaviors•Excellent customer service and interpersonal skills; interact with patients with the desire to respond to and meet their needs, requirements, and expectations.•Excellent written and verbal communication skills. Confidence to communicate and outreach to other community health care organizations and personnel.•Collaborative - establish and maintain a collaborative working environment; focused on customer/end user relationships.•Proven decision-making and problem-solving abilities.•Reporting - translate data into meaningful information in report and/or presentation formats.•Analysis - easily consume, process, and analyze data; make recommendations as to appropriate data strategies and tactics.•Organizational skills; strong attention to detail and accuracy•Multitask and meet deadlines, expert attention to detail.•Maintain the confidentiality of records, documents or discussions related to ACCESS functions.•Strategic Thinking - think strategically level of detail analysis to plan and execute.•Emotional Intelligence - exhibits confidence, empathy and respect when communicating with customers (patients), leadership and staff.•Cultural competency - experience working in a multi-cultural environment; work with diverse persons, and personalities.•Coach and train using written, verbal, and visual methods.Working Conditions/Equipment•Normal office environment•Health Center environment•Remote working options; must have a suitable and secure remote working environment.•Local travel between health centers, hospitals and home/community visits is required; mode of transportation, current driver’s license and proof of insurance is required.•Ability to sit at a desk for up to 4 hours at a time•Ability to stand for up to 2 hours at a time•Computer/Laptop•Phone/Fax/Copier/Scanner EMPLOYEE EXPECTATIONSFollowing are guidelines of expectations for all employees of this organization. These guidelines are incorporated as part of your job description.➢ Maintain current knowledge in your area of skill and expertise and strive to improve your own work.As an employee you are expected to do the following:➢ Report to work on time as scheduled. You should be at your work assignment ready to begin work at scheduled starting times. Observe break times appropriately.➢ Be courteous, friendly, helpful, and supportive. Use a person’s name and use such phrases as “please,” “thank you,” and “may I help you?” whenever appropriate.➢ Make efficient use of your time at work. Establish priorities with your supervisor and use your time wisely.➢ Promote team spirit. Work together and cooperate in an effort to promote quality client services and enhance staff relationships. Help fellow staff members perform their work. Share responsibilities. Recognize others’ achievements➢ Communicate effectively. Be open, honest, and truthful with yourself and others. Talk to your supervisor. Ask questions. Give your supervisor pertinent information, stating the facts without concealing or exaggerating.➢ Anticipate and meet client needs. Be observant of and react to individual client needs. Client dignity is of primary importance.➢ Maintain an appropriate appearance. Make sure clothing is clean and you are neatly groomed. It is important to portray a positive image.➢ Participate in making quality of work better. Suggest improvements to your supervisor. Help others learn correct procedures. Be open to new ideas and methods.➢ Know the structure, philosophy, and purpose of the organization. Know how you fit into the structure and purpose of the organization. Maintain and promote the philosophy of the organization.