POSITION SUMMARY:

The Accountable Care Organization (ACO) Care Coordinator supports the implementation of the patient’s integrated care plan and works towards resolution of patient needs/barriers. The care coordinator carries out delegated functions related to disease states and other conditions that have been deemed to be part of the scope of practice for unlicensed staff members. Their focus is to offer individualized assistance to patients, as well as their families and caregivers to overcome health care system and community barriers and facilitate consistent and timely medical care across the continuum of care. Care coordinators function as members of the integrated care delivery team and provide services in both the hospital setting as well as in Crusader clinics. This position reports to the Chair of the Behavioral Health Department.

ESSENTIAL FUNCTIONS:

1. Accountable for demonstrating the qualities outlined in the “Customer Service Standards of Excellence” when interacting with patients, their families and friends, and fellow employees.

2. Provide appropriate interventions which demonstrate cultural awareness and knowledge of and sensitivity toward cultural diversity, developmental, health literacy, and educational backgrounds of the patients served.

3. Assists and promotes the identification of the targeted patient population who will benefit from care coordination, case management, and other services according to the ACO model.

4. Provide general care coordination orientation to patients and communicate the goals and objectives of the ACO program.

5. Conduct coordination, facility visits, and “rounding” in the hospital setting with inpatient staff and Crusader patients.

6. Perform social determinant of health (SDoH) assessments and link/refer patients with resources based on the assessment.

7. Guide patients through transitions of care from inpatient settings to home.

8. Perform follow-up activities with patients as needed after emergency department visits.

9. Assist with scheduling medical and specialty appointments. Provide reminder phone calls for appointments and/or follow-up calls post appointment.

10. Contact patients to facilitate continuity of care and escalate issues to appropriate team members.

11. Compile and distribute educational material per patient need.

12. Assist patients with adherence to existing self-management goals or development of new goals (in collaboration with clinical staff).

13. Participate in cross-functional team meetings aimed at improving patient outcomes or operational processes.

14. Develop and maintain excellent working knowledge of common chronic conditions and seek information as part of continuous learning.

15. Retrieve discharge summaries and copies of medical records.

16. Collaborates with internal and/or external patient care team(s), across clinics and including hospital staff and community-based resources (conducted in the clinic and/or in the community).

17. Participates in relevant community-based activities and events to promote organizational services.

• Provide crisis intervention and support to patients when appropriate.

19. Participates in quality review processes to assure continual improvement of patient safety, clinical practice, and quality patient care.

20. Documents in a timely manner (per Crusader standards) and as appropriate in the medical record (per Crusader standards)

21. Attains goals mutually established with the Chair within the set time frame.

22. Performs other duties specified by the Chair or designee.

QUALIFICATIONS:

Knowledge of:

• Locating, coordinating, and accessing appropriate services and entitlements for patients.

2. Case Management principles of practice including the formulation of treatment plans, ability to monitor progress, and ability to modify plans to meet patient needs.

EDUCATION/EXPERIENCE/TRAINING:

Education:

1. Bachelor’s degree from an accredited college/university in the human services field (i.e. psychology, social work, sociology, nursing, healthcare, human development and family services).

2. Current or ability to obtain CPR certification.

3. Current with any required Continuing Education requirements.

Certification/License:

1. Certified Medical Assistant certification preferred.

2. Valid driver’s license and insurance.

Experience:

1. Case management/care management experience preferred.

2. Previous experience working in a hospital setting preferred.

3. Previous experience in ambulatory care preferred.

4. Electronic Health Record experience preferred.

Technical Knowledge:

Software: Previous Electronic Medical Record experience, MS Office (Word, Excel, Outlook, PowerPoint), Internet

Equipment: Common office machines

Ability To:

• Assist in the facilitation and coordination of patient care plans.
• Demonstrate and utilize interpersonal communication skills.
• Work independently as well as on a team with a high variety of individuals.
• Utilize efficient time management skills.
• Creatively problem-solve.
• Navigate complex systems of care.
• Exude strong customer service skills.

· Document appropriately in the medical record .

· Accept direction and assistance appropriately in completing assignments.

· Provide an atmosphere of professionalism, privacy, and confidentiality (per Crusader standards and all relevant laws and professional codes of ethics) with all levels of staff, patients, and the public.

• Establish and maintain professional working relationships with all levels of staff, patients, and the public.

Demonstrate attention to details and strong organizational skills

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• In-person

Ability to Relocate:

• Rockford, IL 61102: Relocate before starting work (Required)

Work Location: In person