Summary:The Care Coordinator will serve as a member of the integrated care team to provide care coordination services to clients, through collaboration and continuous partnership with chronically ill and high-risk patients. The Care Coordinator will work with the client’s families and caregivers, specialty providers, clinics, hospitals, other care providers, and community resources in a team approach to ensure that all elements of a care plan, referrals, and support are in place. The Care Coordinator will conduct telephone outreach to clients in need of follow-up care, care gaps as noted, and no-show appointments. The Care Coordinator will serve as a central point for answering calls for various health centers and will assist patients in scheduling and canceling appointments, answer non-clinical patient questions, and direct callers to appropriate parties and resources.The Care Coordinator may be actively involved in developing on-site programs and coordinating with population Health for promotion materials, site management, and providers.

The Care Coordinator will participate in the Patient-Centered Medical Home Team care process.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Active staff in CFH call center, screens calls, transitioning messages to correct resource and provide information CFH patients.
• Assist patients over the phone in scheduling and canceling appointments at CFH Health Centers.
• Conduct targeted phone outreach to patients in need of follow-up care or screenings
• Work with patients to ensure they are linked to care, including primary care and specialty care
• Monitor patients’ adherence to medical appointments, and reach out to patients who have missed appointments or have fallen out of care, with the intent to re-link patients to services.
• Connect patients to relevant community resources, including lifestyle change classes, food access programs, fitness classes, legal services, etc.
• Ensures patients receive timely access to appropriate care across disciplines and provides advocacy on behalf of patients when needed
• Work with patients to ensure they attend referral specialty appointments and assist patients in addressing any barriers in attending appointments.
• Assist in the implementation of transition of care protocols.
• Coordinate with Population Health to develop programming events to ensure all involved are aware of site-based events.
• Primary function will be to assist with the facilitation of front desk operations.
• Facilitate internal referral to other services and provide nonclinical community referral linkages and monitoring.
• Participate in Integrated Care Team huddles, team meetings, and interdisciplinary conferences.
• Assist the patient in selecting or switching a Primary Care Provider (PCP).
• Ensures patient’s comfort by promptly addressing any questions, concerns, and anxieties and maintains a welcoming and comfortable reception area.
• Protects patients’ rights by maintaining confidentiality of personal and financial information, and complies with State, Federal and Practice Guidelines

JOB QUALIFICATIONS:

Education:

• Bachelor’s Degree in Social Work, Public Health, or a related field.

Experience:

• 1-2 years of experience in care coordination, patient service, or patient outreach.
• Previous experience providing services and exercising leadership in a culturally and linguistically diverse setting, with demonstrated success.
• Prior experience in a health care setting, preferably FQHCs, strongly preferred.

Skill Sets:

• Strong organizational skills: able to manage diverse responsibilities and provide services at various sites.
• Ability to establish and maintain effective working relationships with colleagues, clients and contracted providers of health care services.
• Strong problem-solving skills and ability to address issues professionally and effectively.
• Excellent oral and written communication skills needed to provide counseling to clients, document casework and , providetraining.
• Ability to work both independently and within a team environment.
• Bilingual English/Spanish strongly preferred.