POSITION SUMMARY:

This position is responsible for managing high risk, chronic illness patients to promote effective education, self-management support and timely healthcare delivery to achieve optimal quality and financial outcomes. Responsibilities include coordinating patient care to improve quality of care through the efficient use of resources and thereby enhancing quality, cost-effective outcome. Acts as an advocate for the individual’s healthcare needs, and coordinates care to minimize the fragmentation of health care delivery systems. This position is committed to the constant pursuit of excellence in improving the health status of the community.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Collaborates with providers and practice staff in identifying appropriate patients for care management, utilizing established Care Management criteria.
• Performs initial and periodic holistic assessments for care-managed population. This includes physical and psychological assessments as appropriate. The assessment includes a systematic and pertinent collection of data about the health status of the patient. Prioritize patients according to intensity, need and required follow up.
• Formulates and implements a care management plan that addresses the patients identified needs by assessing the patient/family needs, issues, resources, and care goals; determining the choices available to individual patients; educating the patient/family on the choices available.
• Establishes a care management plan that is mutually agreed upon by the health care team and the patient/family. Plans will contain specific mutual self-management goals, objectives, and interventions with the patients are action oriented.
• Evaluates the effectiveness of the plan in meeting established care goals; revises the plan as needed to reflect changing needs, issues, and goals. Monitors and evaluates the progress of the patient.
• Collaborates with the healthcare team to revise the care management plan when changes occur. Initiates care conferences to discuss multidisciplinary team responsibilities, patient progress, new problems, etc.
• Identifies and effectively utilizes community resources to meet the needs of patients/families.
• Facilitates patient access to community resources as appropriate or refers to SW.
• Promotes patient self-management and empowers patients/families to achieve maximum levels of wellness and independence. Interacts professionally with patient/family and involves patient/family in the formation of plan of care.
• Performs follow up calls for patients recently discharged from acute hospitalizations and who are considered high risk for readmission.
• Maintains EMR databases on care managed population. Maintains accurate and timely documentation in the EMR
• Reviews utilization and quality reports routinely and scans for gaps in care to identify patients needing the additional support of care management.
• Performs all duties and responsibilities in accordance with the Nurse Practice Act and in accordance with basic principles and guidelines of professional nursing.
• Performs medication reconciliation for all care transitions.
• Participates in regular team meetings and peer review activities. Participates in quality and organizational committees.
• Participates in the orientation of new personnel. Precepts and mentors’ peers. Promotes collaborative teamwork.
• Abides by the organization’s compliance program and requirements.
• Provides coverage across the organization as needed.
• Works collaboratively with leadership team to improve and enhance care delivery through the evaluation, development and enhancement of policy and procedures.

COMPETENCIES:

• Good organizational skills to handle multiple priorities while remaining professional and calm.
• Ability to work with many diverse people.
• Effective telephone skills.
• Strong level of confidentiality due to the sensitivity of materials and information handled.
• Must be able to make suggestions on workflow or system efficiency and effectiveness.
• Ability to work independently and be self-directed and flexible.
• Ability to prioritize.
• Ability to perform functions with minimal supervision.
• Ability to work at a high-volume level of accuracy.

GENERAL EXPECTATIONS:

• Be committed to the mission of Doral Health and Wellness
• Behave in a professional manner and consistently demonstrate and promote the values of respect, honesty, and dignity for the patient, families, and all members of the healthcare team. Committed to the constant pursuit of excellence and teamwork in improving the care of the patient and families of Doral Health and Wellness
• Be punctual for scheduled work and use time appropriately.
• Maintain confidentiality and protect the Practice by abiding by laws and principles related to confidentiality; keep information concerning Practice Operations, patients, and employees confidential.
• This position requires compliance with Health Center’s compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element considered as part of the Care Coordinator’s regular performance evaluation.
• Perform required amount of work in a timely fashion with a minimum of errors.
• Be neat and maintain a professional appearance.
• Perform duties in a conscientious, cooperative manner.

PHYSICAL REQUIREMENTS:

The physical requirements described here are representative of those that must be met by the Incumbent 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 sit for prolonged periods of time and talk and hear. The employee is occasionally required to stand, walk, and use hands to operate a standard computer keyboard. The employee may occasionally lift and/or move up to 10 pounds. Vision requirements include close vision, distance vision, depth perception, and the ability to adjust focus.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those the incumbent encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work is performed in a busy medical office environment with many interruptions. Noise level is moderate. Very active, fast paced position with short deadlines. At times, must interact with irate patients and remain calm and professional. High risk exposure to blood borne pathogens and chemical hazards.

QUALIFICATIONS NEEDED FOR POSITION:

Experience and Skill Requirements: The following experience and skills are considered essential:

• Minimum of 3 year of professional level medical experience; experience in care coordination preferred.
• Experience working with an electronic medical record required.
• Ability to work collaboratively with people of diverse cultures and lifestyles.
• Ability to communicate effectively with providers and medical staff.
• Excellent organizational skills and ability to handle multiple priorities while remaining calm and professional.
• Ability to be self-motivating and work independently.
• Computer skills proficient to expert
• Excellent written and oral communication skills.
• Problem solving skills.

Education Requirements: The following education requirements are considered essential:

• Medical Assisting Associate Degree
• Proficiency in medication indications and side effects.
• Understanding of medical tests and requirements for test as to provide the patients with appropriate information.

** All requirements and skills are essential, unless otherwise indicated. *

Job Type: Full-time

Pay: $24.00 per hour

Benefits:

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

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• In-person

Language:

• Spanish (Preferred)

License/Certification:

• Certified Medical Assistant (Required)

Work Location: In person