Department: Patient Centered Services

Manager Title: Care Coordination Manager

FLSA Status: Non-Exempt

• Providers excellent customer service to internal and external customers
• Engages patients as active participants in their care
• Assists patients in scheduling and completing referrals as needed by coordinating between the patient, provider(s), and the referral source

o Establish relationships to coordinate patient referrals between patients provider and referral source to promote patient-centered services and ensure all reports are received by PCC

• Collaborate with providers, patients, AND AmeriCorps members to provide patients services needed for successful follow-up
• Advocate on patients behalf if needed to ensure completion of referrals

• Decrease barriers to care, increase motivation, and foster open communication
• Contact referral sources when reports/results are outstanding, request results/reports not automatically received by PCC
• Directs all reports to primary care provider.
• Notifies primary care provider of any incomplete/unsuccessful referrals
  • Produce basic reports
  • Achieve outcome-based metrics for performance
  • Maximize services within care coordinator scope and refer to other staff as needed based on patients need and staff members position, licensure and scope of services
• Prepare data and documentation and have charts prepped for all applicable Case Management sessions
• Regularly attend and participate in monthly site team meetings
• Contribute to patient education materials and strategies to support care coordination
• Work with manager and team to create flow charts, workflows and document tracking process as needed
• Work with PI department to utilize computerized databases for tracking of identified high-risk areas by collecting, reviewing and inputting data into database and following up on all failed follow-up visits per program guidelines
• Follow guidelines to enhance care coordination for high-need, high-risk patients, tracking of high-risk areas as needed

• Develop supportive services and tools to address common barriers to care for PCC patients; integrate these with other initiatives for health promotion/education and access to care
• Performs other duties as required and assigned

Experience/Training:

• High school diploma required.
• Medical Assistant diploma from an accredited Medical Assistant program preferred.
• Certified or Registered Medical Assistant preferred.
• Associates or Bachelors degree preferred.
• Previous healthcare experience preferred
• Proficient in MS Office Business Application to include: Outlook, Word, PowerPoint and Excel

Physical Demands:

• Must be able to remain in a stationary position 50% of the time.
• Must be able to move around the clinic site 50% of the time.
• Constantly operates a computer, computer printer, copy machine, and telephone.
• Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
• Must be able to transport from one site to another.
• Must be able to cover other shifts as necessary.
• Required shift rotation.

Other Skills:

• Ability to read and write proficiently using the English language.
• Constantly communicates with other healthcare providers. Must be able to exchange accurate information in these situations.
• Follow-through, assume responsibility and use good judgment.
• Maintain professionalism under stressful situations.
• Self-motivated and directed with the ability to prioritize and work efficiently under pressure.
• Ability to understand and follow verbal and written communication.
• Detail oriented with the ability to work with minimal/no supervision.
• Willingness to be part of a team-unit and cooperate in the accomplishment of departmental goals and objectives.
• Effective and creative problem solving.